Thank you for helping us maintain our safety records. You need to sit and fill this out with your allocated LTO staff member as you'll both need to fill parts of this form in. Company Title Choose One Mr. Ms. Mrs. Prof. Dr. To be filled out by the expedition participant First Name * To be filled out by the expedition participant Last Name * To be filled out by the expedition participant Email Address * To be filled out by the expedition participant Contact Number * To be filled out by the expedition participant Home address * To be filled out by the expedition participant Postcode * To be filled out by the expedition participant Occupation * To be filled out by the expedition participant LTO staff Title Choose One Mr. Ms. Mrs. Prof. Dr. To be filled out by the LTO staff member LTO staff First Name * To be filled out by the LTO staff member LTO staff Last Name * To be filled out by the LTO staff member LTO staff Email Address * To be filled out by the LTO staff member LTO staff Contact number * To be filled out by the LTO staff member LTO staff home address * To be filled out by the LTO staff member LTO staff postcode * To be filled out by the LTO staff member LTO staff occupation * To be filled out by the LTO staff member Linked to a previous report? Yes No Date of incident: Summary of incident Time of incident: Summary of incident Location of incident: Summary of incident Did the person suffer any injury? If so, what? Summary of incident How (inc cause if possible) Summary of incident Print name & current date To be filled out by LTO staff member Category 1 - Death 2 - Emergency evacuation with subsequent repatriation for medical attention 3 - Non-emergency evacuation 4 - Hospital treatment required in local area 5 - Treatment on site - serious illness/injury 6 - Treatment on site - moderate illness/injury 7 - Treatment on site - minor illness/injury 8 - Near miss If linked to previous report do not fill in this section By ticking this box I give my consent to disclose my personal information and details of the accident which appear on this form to safety representatives for them to carry out the health and safety functions given to them by law By ticking this box I give my consent to disclose my personal information and details of the accident which appear on this form to safety representatives for them to carry out the health and safety functions given to them by law https://lovetheoceans.org/privacy-statement/ * Print name & current date To be filled out by expedition participant Further comments Information Summary Connect with us Facebook Twitter Instagram Youtube Linkedin POPULAR PAGES 4 WEEK RESEARCH PROGRAM2 WEEK RESEARCH PROGRAMCONSERVATION ADVENTURE PROGRAMCONSERVATION ARTICLES USEFUL PAGES CONTACT USOUR TEAMWHY LOVE THE OCEANS?OUR ETHICAL STANDARDSVOLUNTEER TESTIMONIALS GENERAL PAGES PRIVACY POLICYHEALTH AND SAFETYFINANCIAL PROTECTIONFAQsTERMS AND CONDITIONS SUBSCRIBE TO OUR NEWSLETTER SUBSCRIBE TO OUR NEWSLETTERSUBSCRIBE TO OUR NEWSLETTER We won't spam you, we promise.Invalid email addressThanks for subscribing! Please check your email for confirmation. 22 Wycombe End, Beaconsfield, Buckinghamshire, HP9 1NB, UKinfo@lovetheoceans.org | (0044) 7881 795 062 © Copyright 2019 Love The Oceans Love The Oceans Conservation charity number 1184402 Registered in England and Wales Share this:TwitterFacebookLike this:Like Loading...