Was the incident a near miss (i.e. an incident without injury)?

\n","dirty":true,"text":"Header","content":"

Was the incident a near miss (i.e. an incident without injury)?

Medical Treatment:

\n","dirty":true,"text":"Header","content":"

Medical Treatment:

\n","canHaveAnswer":true,"canHaveAlternateForm":true,"canHaveDisplayHorizontal":true,"canHaveOptionCorrect":true,"canHavePageBreakBefore":false,"canHaveOptionValue":false,"prefix":"checkboxes_","canPopulateFromApi":true,"allowPopulate":true,"inline":true,"center":false,"options":[{"value":"","text":"No Treatment","key":"E2505034-AC45-4575-83F7-B5308C30ED56","correct":true},{"value":"","text":"First Aid","key":"5054B282-6F91-4F35-8237-034AA9FD3A46"},{"value":"","text":"SETU Nurse","key":"16450DEB-7C3A-4DA5-9022-FB16C612C878"},{"value":"","text":"SETU Doctor","key":"36E98C6D-7924-4FA5-A747-D6A127367B8B"},{"value":"","text":"GP/Caredoc","key":"5807C52E-D63C-4F8D-B343-7E16F2FC233A"},{"value":"","text":"Hospital","key":"27F9BA27-A780-4BD4-B2ED-DE5B2EC28F00"},{"value":"","text":"Other","key":"255D3FC4-7F58-4D91-B97E-5D5367F28919"}],"sort":false,"layout":{"width":128,"height":111,"posX":0,"posY":46.363636363636374},"parentId":"66E5F939-04D8-4E3F-B2B2-BCC0DED004EE","fieldVisibilityMode":"HIDE","lockField":{"mode":"ALL","fieldName":"checkboxes_C39DF6D4-2EA2-4450-9640-75E4A8CA833C","fieldValues":["649D1EA7-CB24-453B-B789-CD65D29D7FC0"]}},{"id":"2ED561C8-21B9-4192-94AF-4A1B8256DCFB","element":"TextInput","field_name":"text_input_2ED561C8-21B9-4192-94AF-4A1B8256DCFB","required":false,"label":"Name of first aid responder (if known)?","bold":false,"italic":false,"dirty":true,"text":"Header","content":"Header","canHaveAnswer":true,"canHaveAlternateForm":true,"canHaveDisplayHorizontal":true,"canHaveOptionCorrect":true,"canHavePageBreakBefore":false,"canHaveOptionValue":false,"prefix":"text_input_","canPopulateFromApi":false,"allowPopulate":false,"inline":false,"center":false,"layout":{"width":128,"height":90.00000000000001,"posX":0,"posY":57.363636363636374},"parentId":"66E5F939-04D8-4E3F-B2B2-BCC0DED004EE","fieldVisibilityMode":"HIDE","lockField":{"mode":"ALL","fieldName":"checkboxes_448265B2-7CDD-4027-854D-295D1F25C9D9","fieldValues":["5054B282-6F91-4F35-8237-034AA9FD3A46"]}},{"id":"E2AC656C-D4A4-4FBD-8E30-0275638A1D56","element":"TextInput","field_name":"text_input_E2AC656C-D4A4-4FBD-8E30-0275638A1D56","required":false,"label":"Please provide details of first aid administered:","bold":false,"italic":false,"dirty":true,"text":"Header","content":"Header","canHaveAnswer":true,"canHaveAlternateForm":true,"canHaveDisplayHorizontal":true,"canHaveOptionCorrect":true,"canHavePageBreakBefore":false,"canHaveOptionValue":false,"prefix":"text_input_","canPopulateFromApi":false,"allowPopulate":false,"inline":false,"center":false,"layout":{"width":128,"height":90.00000000000001,"posX":0,"posY":66.45454545454547},"parentId":"66E5F939-04D8-4E3F-B2B2-BCC0DED004EE","fieldVisibilityMode":"HIDE","lockField":{"mode":"ALL","fieldName":"checkboxes_448265B2-7CDD-4027-854D-295D1F25C9D9","fieldValues":["5054B282-6F91-4F35-8237-034AA9FD3A46"]}},{"id":"2C066DC7-DD85-4B36-8BEE-69AD3D33BBFA","element":"TextInput","field_name":"text_input_2C066DC7-DD85-4B36-8BEE-69AD3D33BBFA","required":false,"label":"Please provide details of medical practitioner who administered treatment i.e. GP Practice/Caredoc/Dentist/Optician (if known):","bold":false,"italic":false,"dirty":true,"text":"Header","content":"Header","canHaveAnswer":true,"canHaveAlternateForm":true,"canHaveDisplayHorizontal":true,"canHaveOptionCorrect":true,"canHavePageBreakBefore":false,"canHaveOptionValue":false,"prefix":"text_input_","canPopulateFromApi":false,"allowPopulate":false,"inline":false,"center":false,"layout":{"width":128,"height":100,"posX":0,"posY":75.54545454545456},"parentId":"66E5F939-04D8-4E3F-B2B2-BCC0DED004EE","fieldVisibilityMode":"HIDE","lockField":{"mode":"ALL","fieldName":"checkboxes_448265B2-7CDD-4027-854D-295D1F25C9D9","fieldValues":["5807C52E-D63C-4F8D-B343-7E16F2FC233A","255D3FC4-7F58-4D91-B97E-5D5367F28919"]}},{"id":"895968F9-EFCC-4679-A118-BE8EE21604DA","element":"TextInput","field_name":"text_input_895968F9-EFCC-4679-A118-BE8EE21604DA","required":false,"label":"Which hospital did you attend?","bold":false,"italic":false,"dirty":true,"text":"Header","content":"Header","canHaveAnswer":true,"canHaveAlternateForm":true,"canHaveDisplayHorizontal":true,"canHaveOptionCorrect":true,"canHavePageBreakBefore":false,"canHaveOptionValue":false,"prefix":"text_input_","canPopulateFromApi":false,"allowPopulate":false,"inline":false,"center":false,"layout":{"width":128,"height":90.00000000000001,"posX":0,"posY":85.54545454545456},"parentId":"66E5F939-04D8-4E3F-B2B2-BCC0DED004EE","fieldVisibilityMode":"HIDE","lockField":{"mode":"ALL","fieldName":"checkboxes_448265B2-7CDD-4027-854D-295D1F25C9D9","fieldValues":["27F9BA27-A780-4BD4-B2ED-DE5B2EC28F00"]}},{"id":"D546D273-235A-40F1-AFBE-F232533FB7B3","element":"TextInput","field_name":"text_input_D546D273-235A-40F1-AFBE-F232533FB7B3","required":false,"label":"If you were admitted to hospital, how long was your stay in hospital?","bold":false,"italic":false,"dirty":true,"text":"Header","content":"Header","canHaveAnswer":true,"canHaveAlternateForm":true,"canHaveDisplayHorizontal":true,"canHaveOptionCorrect":true,"canHavePageBreakBefore":false,"canHaveOptionValue":false,"prefix":"text_input_","canPopulateFromApi":false,"allowPopulate":false,"inline":false,"center":false,"layout":{"width":128,"height":90.00000000000001,"posX":0,"posY":94.63636363636365},"parentId":"66E5F939-04D8-4E3F-B2B2-BCC0DED004EE","fieldVisibilityMode":"HIDE","lockField":{"mode":"ALL","fieldName":"checkboxes_448265B2-7CDD-4027-854D-295D1F25C9D9","fieldValues":["27F9BA27-A780-4BD4-B2ED-DE5B2EC28F00"]}},{"id":"99BAF596-0B04-4369-BDE0-41645680B50B","element":"TextInput","field_name":"text_input_99BAF596-0B04-4369-BDE0-41645680B50B","required":false,"label":"Name of person completing form:","bold":false,"italic":false,"dirty":true,"text":"Header","content":"Header","canHaveAnswer":true,"canHaveAlternateForm":true,"canHaveDisplayHorizontal":true,"canHaveOptionCorrect":true,"canHavePageBreakBefore":false,"canHaveOptionValue":false,"prefix":"text_input_","canPopulateFromApi":false,"allowPopulate":false,"inline":false,"center":false,"layout":{"width":128,"height":90.00000000000001,"posX":0,"posY":122.81818181818184},"parentId":"66E5F939-04D8-4E3F-B2B2-BCC0DED004EE","fieldVisibilityMode":"SHOW"},{"id":"9F146CB7-A5A3-4389-82D0-F7CB7BCB869E","element":"RadioButtons","field_name":"radio_9F146CB7-A5A3-4389-82D0-F7CB7BCB869E","required":false,"label":"

Was an ambulance required?

\n","dirty":true,"text":"Header","content":"

Was an ambulance required?

\n","canHaveAnswer":true,"canHaveAlternateForm":true,"canHaveDisplayHorizontal":true,"canHaveOptionCorrect":true,"canHavePageBreakBefore":false,"canHaveOptionValue":false,"prefix":"radio_","canPopulateFromApi":true,"allowPopulate":true,"inline":true,"center":false,"options":[{"value":"","text":"Yes","key":"882A24D2-B8D6-45D6-91D8-E5A24279946B","correct":false},{"value":"","text":"No","key":"089D04C7-1E05-4C9D-8482-69B3A199E60D"}],"sort":false,"layout":{"width":128,"height":100,"posX":0,"posY":103.72727272727275},"parentId":"66E5F939-04D8-4E3F-B2B2-BCC0DED004EE","fieldVisibilityMode":"HIDE","lockField":{"mode":"ALL","fieldName":"checkboxes_C39DF6D4-2EA2-4450-9640-75E4A8CA833C","fieldValues":["649D1EA7-CB24-453B-B789-CD65D29D7FC0"]},"sectionRequiredController":false},{"id":"F481A182-DB91-4EDD-B0FD-682C4C44660C","element":"TextInput","field_name":"text_input_F481A182-DB91-4EDD-B0FD-682C4C44660C","required":false,"label":"How many days were you absent from work or study?:","bold":false,"italic":false,"dirty":true,"text":"Header","content":"Header","canHaveAnswer":true,"canHaveAlternateForm":true,"canHaveDisplayHorizontal":true,"canHaveOptionCorrect":true,"canHavePageBreakBefore":false,"canHaveOptionValue":false,"prefix":"text_input_","canPopulateFromApi":false,"allowPopulate":false,"inline":false,"center":false,"layout":{"width":128,"height":90.00000000000001,"posX":0,"posY":113.72727272727275},"parentId":"66E5F939-04D8-4E3F-B2B2-BCC0DED004EE","fieldVisibilityMode":"HIDE","lockField":{"mode":"ALL","fieldName":"checkboxes_C39DF6D4-2EA2-4450-9640-75E4A8CA833C","fieldValues":["649D1EA7-CB24-453B-B789-CD65D29D7FC0"]}},{"id":"EC2ABD7C-FA37-4FC3-A123-7B6F1282F1AC","element":"Download","field_name":"file_EC2ABD7C-FA37-4FC3-A123-7B6F1282F1AC","required":false,"label":"Please upload any photos/documents relevant to the incident here?","bold":false,"italic":false,"dirty":true,"text":"Header","content":"Header","canHaveAnswer":true,"canHaveAlternateForm":true,"canHaveDisplayHorizontal":true,"canHaveOptionCorrect":false,"canHavePageBreakBefore":false,"canHaveOptionValue":false,"prefix":"file_","canPopulateFromApi":false,"allowPopulate":false,"inline":false,"center":false,"layout":{"width":128,"height":220,"posX":0,"posY":296.90909090909093}},{"id":"93BE1BD6-7C1B-4925-9A29-2B2C0A8481AA","element":"TextInput","field_name":"text_input_93BE1BD6-7C1B-4925-9A29-2B2C0A8481AA","required":false,"label":"Name of witness (if applicable and known):","bold":false,"italic":false,"dirty":true,"text":"Header","content":"Header","canHaveAnswer":true,"canHaveAlternateForm":true,"canHaveDisplayHorizontal":true,"canHaveOptionCorrect":true,"canHavePageBreakBefore":false,"canHaveOptionValue":false,"prefix":"text_input_","canPopulateFromApi":false,"allowPopulate":false,"inline":false,"center":false,"layout":{"width":63,"height":90.00000000000001,"posX":0,"posY":50.00000000000001},"parentId":"EB96D092-9C56-4399-9CF1-97ABB8892DA9"},{"id":"9F068D46-A6CE-47D5-BC6F-CFC46371A1D3","element":"TextInput","field_name":"text_input_9F068D46-A6CE-47D5-BC6F-CFC46371A1D3","required":false,"label":"Contact number or email address of witness (if applicable and known)","bold":false,"italic":false,"dirty":true,"text":"Header","content":"Header","canHaveAnswer":true,"canHaveAlternateForm":true,"canHaveDisplayHorizontal":true,"canHaveOptionCorrect":true,"canHavePageBreakBefore":false,"canHaveOptionValue":false,"prefix":"text_input_","canPopulateFromApi":false,"allowPopulate":false,"inline":false,"center":false,"layout":{"width":64,"height":90.00000000000001,"posX":63,"posY":50.00000000000001},"parentId":"EB96D092-9C56-4399-9CF1-97ABB8892DA9"},{"id":"6BC604CB-EBE0-4D1C-83D8-5FB1FBC96E90","element":"Dropdown","field_name":"dropdown_6BC604CB-EBE0-4D1C-83D8-5FB1FBC96E90","required":true,"label":"Which side of body was injured?","bold":false,"italic":false,"dirty":true,"text":"Header","content":"Header","canHaveAnswer":true,"canHaveAlternateForm":true,"canHaveDisplayHorizontal":true,"canHaveOptionCorrect":true,"canHavePageBreakBefore":false,"canHaveOptionValue":false,"prefix":"dropdown_","canPopulateFromApi":true,"allowPopulate":true,"inline":false,"center":false,"options":[{"value":"1","text":"Right hand side","key":"C2267B0C-5C40-403E-8646-CA9AF8C6B74F","correct":true},{"value":"2","text":"Left hand side","key":"EE7F6070-FDEB-439B-AAD8-26CDC5680B17"},{"value":"3","text":"Multiple areas","key":"B8390D60-E538-4ED0-BAE8-A6A6B5D06A83"}],"sort":false,"layout":{"width":128,"height":90.00000000000001,"posX":0,"posY":37.27272727272728},"parentId":"66E5F939-04D8-4E3F-B2B2-BCC0DED004EE","fieldVisibilityMode":"HIDE","lockField":{"mode":"ALL","fieldName":"checkboxes_C39DF6D4-2EA2-4450-9640-75E4A8CA833C","fieldValues":["649D1EA7-CB24-453B-B789-CD65D29D7FC0"]}},{"id":"6EBBEC07-1D49-4186-8D64-F4C1FEE61CCC","element":"TextInput","field_name":"text_input_6EBBEC07-1D49-4186-8D64-F4C1FEE61CCC","required":false,"label":"Department:","bold":false,"italic":false,"dirty":true,"text":"Header","content":"Header","canHaveAnswer":true,"canHaveAlternateForm":true,"canHaveDisplayHorizontal":true,"canHaveOptionCorrect":true,"canHavePageBreakBefore":false,"canHaveOptionValue":false,"prefix":"text_input_","canPopulateFromApi":false,"allowPopulate":false,"inline":false,"center":false,"layout":{"width":63,"height":100,"posX":0,"posY":18.181818181818183},"parentId":"2C608120-B4A6-4F2D-8192-715E8917CDDF","fieldVisibilityMode":"HIDE","lockField":{"mode":"ONE","fieldName":"dropdown_8EEB7263-7CA1-47BA-A514-4E27DFA06BE1","fieldValues":["72BCC518-A204-460D-A3F9-A19FD13A323A","43B3DC80-4D52-4FE5-B4A3-0BEA6A46ED91","6E6CF46F-97B9-42E7-A0C1-653502297361","1796894C-6511-4A97-B81D-BE3263799CC4"]}},{"id":"B1D5611B-0019-466D-BAF6-D2ACDB57753F","element":"TextInput","field_name":"text_input_B1D5611B-0019-466D-BAF6-D2ACDB57753F","required":false,"label":"Course of Study:","bold":false,"italic":false,"dirty":true,"text":"Header","content":"Header","canHaveAnswer":true,"canHaveAlternateForm":true,"canHaveDisplayHorizontal":true,"canHaveOptionCorrect":true,"canHavePageBreakBefore":false,"canHaveOptionValue":false,"prefix":"text_input_","canPopulateFromApi":false,"allowPopulate":false,"inline":false,"center":false,"layout":{"width":63,"height":90.00000000000001,"posX":0,"posY":28.181818181818183},"parentId":"2C608120-B4A6-4F2D-8192-715E8917CDDF","fieldVisibilityMode":"HIDE","lockField":{"mode":"ONE","fieldName":"dropdown_8EEB7263-7CA1-47BA-A514-4E27DFA06BE1","fieldValues":["6E6CF46F-97B9-42E7-A0C1-653502297361","1796894C-6511-4A97-B81D-BE3263799CC4"]}},{"id":"8E8F0B64-1858-4D39-9534-B723B966FBE9","element":"TextInput","field_name":"text_input_8E8F0B64-1858-4D39-9534-B723B966FBE9","required":false,"label":"Year of Study:","bold":false,"italic":false,"dirty":true,"text":"Header","content":"Header","canHaveAnswer":true,"canHaveAlternateForm":true,"canHaveDisplayHorizontal":true,"canHaveOptionCorrect":true,"canHavePageBreakBefore":false,"canHaveOptionValue":false,"prefix":"text_input_","canPopulateFromApi":false,"allowPopulate":false,"inline":false,"center":false,"layout":{"width":63,"height":90.00000000000001,"posX":63,"posY":27.272727272727273},"parentId":"2C608120-B4A6-4F2D-8192-715E8917CDDF","fieldVisibilityMode":"HIDE","lockField":{"mode":"ONE","fieldName":"dropdown_8EEB7263-7CA1-47BA-A514-4E27DFA06BE1","fieldValues":["6E6CF46F-97B9-42E7-A0C1-653502297361","1796894C-6511-4A97-B81D-BE3263799CC4"]}},{"id":"90B99D6E-0359-4A0B-955F-741D5E27C21D","element":"Header","field_name":"header_90B99D6E-0359-4A0B-955F-741D5E27C21D","label":"

SETU Accident Report Form V1.0

\n","allowNA":false,"allowBlockNext":false,"dirty":true,"text":"Header","content":"

SETU Accident Report Form V1.0

\n","canHaveAnswer":false,"canHaveAlternateForm":true,"canHaveDisplayHorizontal":true,"canHaveOptionCorrect":false,"canHavePageBreakBefore":false,"canHaveOptionValue":false,"prefix":"header_","canPopulateFromApi":false,"allowPopulate":false,"inline":false,"center":false,"layout":{"width":128,"height":90.00000000000001,"posX":0,"posY":0}}]

General Details

SETU Accident Report Form (v1.0)