• Current Key details
  • About the person affected
  • Details of person completing the form
  • Complete

Key details

Please describe the accident, incident or near-miss, including events that lead to it, and any equipment involved.

About the person affected

Name
Click here to enter your address manually.

For injuries only

If applicable.

Details of person completing the form

Witness Details

Only answer this section if the person completing the form is different to the witness. 
Name
Address
If there are any other witnesses to the accident, incident or near-miss please add their details here.

Details of person completing the form

Please complete the details of the person completing this form. 
Name
Click here to enter your address manually.

The MND Association will record information about you, such as contact details, to allow us to keep in touch with you as a volunteer. We may occasionally share your information with appropriate staff and volunteers, but the Association will take good care of your data and will not share it with anyone outside of the Association without asking you first.

For further information on how your data is collected and used please see our volunteer information guide.