Event Information Questionnaire

Company

This field is for validation purposes and should be left unchanged.

Dear Organiser

Thank you for contacting the Northern Ireland Ambulance Service HSC Trust about your proposed event.

We would be grateful if you could take a few minutes to complete and submit the online questionnaire.

If required, this information may be shared with appropriate Northern Ireland Ambulance Service staff as it is extremely useful in assisting us in planning operational activity on the day and considering the potential local impact of your event. All information provided is processed in line with the Data Protection Act 1998.

Please note that the Northern Ireland Ambulance Service HSC Trust can only act on the information provided by you and cannot accept any liabilities in relation to errors or omissions.

Please tick to Agree*

Please tick to confirm that you have read the information above and agree and to proceed to complete and submit Event Information Questionnaire.

Dear Organiser,

Thank you for contacting us about your event.

Please complete the questionnaire below. This will constitute formal notification to the Trust of your event and will enable us to work out the best way to support you in running a safe event.

All information provided is processed in line with the Data Protection Act 1998.

Event Organiser Contact Details

Event Organiser Name*

First Last

Address

Street Address Address Line 2 City County Postcode

Phone

Email*

Medical Manager (or person with responsibility for medical cover)

Medical Manager Name*

This is the name of the person from the event organiser who has overall responsibility for the medical cover. An event organiser may have delegated this responsibility. Please insert name of person with overall responsibility for the medical cover.

First Last

Phone*

Email*

Planned Medical Cover (if arranged)

First Aid Staff Numbers*

Ambulance Numbers (Ambulances should include a suitably qualified crew in addition to the First Aid numbers)*

Other Provision (Paramedic, Nurse, Doctor)*

E.g. Doctors, Paramedics etc

Emergency Contact Details

Please provide the name and contact details for personnel who will be in attendance at the event.

Event Manager or Nominated Deputy

Event Manager or Nominated Deputy Name*

This is the name of the person from the event organiser who has responsibility for the medical cover and WHO WILL BE IN ATTENDANCE AT THE EVENT. Please insert the name of the Event Manager or their nominated deputy.

First Last

Phone*

Email

Risk Assesment

Please upload a copy of any event plans/ medical risk assessments.

Max. file size: 40 MB.

Medical Provider or Nominated Deputy

Medical Provider or Nominated Deputy Name*

This is the name of the person from the lead person from the Medical Provider organisation WHO WILL BE IN ATTENDANCE AT THE EVENT. Please insert the name of the Medical Provider or their nominated deputy.

First Last

Phone*

Email

The Northern Ireland Ambulance Service HSC Trust can only act on the information provided by you and cannot accept any liabilities in relation to errors or omissions.

Please return to page 1, read the statement and tick to agree to continue.

Event Information Questionnaire

Event Organiser Contact Details

Event Details

Medical Manager (or person with responsibility for medical cover)

Planned Medical Cover (if arranged)

Emergency Contact Details

Event Manager or Nominated Deputy

Medical Provider or Nominated Deputy