Medical Event Cover Booking & Risk Assessment Form

Section 1 - Your Information

Please complete All the fields within this section as we will need the information to contact you if needed for further information and to send you a risk assessment review and quotation.

Your Name (required)

Your Organisation Name (required)

Your Email (required)

Landline Number (required)

Name of Event (required)

Address and Postcode of the Event (required)

Event Date and Times (required)
Insert Date(s):
Time: 1.002.003.004.005.006.007.008.009.0010.0011.0012.0013.0014.0015.0016.0017.0018.0019.0020.0021.0022.0023.0024.00 to 1.002.003.004.005.006.007.008.009.0010.0011.0012.0013.0014.0015.0016.0017.0018.0019.0020.0021.0022.0023.0024.00

Section 2 - Risk Assessment

Please answer all of the questions below. You can select multiple answers by holding down the "CNTL" Key and clicking on all the answers within the section. If you are not sure or require further information regarding any of the questions below, please contact us.

Type of Event
---Sports Event Track and FieldEquestrian EventBoxing/Martial ArtsClassical PerformancePublic ExhibitionPop/Rock ConcertDance EventAgricultural/County ShowMarineMotorcycle DisplayAviationMotor SportState OccasionsVIP visits/summitsMusic FestivalBonfire/Pyrotechnic displayNew Year Celebration

Venue/Location of Event
---IndoorStadiumOutdoor in Confined locationOther Outdoor (eg, Festival)Widespread public location in streetsTemporary Outdoor StructureIncludes overnight camping

Standing/Seated
---SeatedMixedStanding

Audience Profile
---Full Mix, in family groupsFull Mix, not in family groupsPredominately young AdultsPredominately children and TeenagersPredominately Elderly

Past History
---Good data, low casualty rate previously (less than 1%)Good date medium casualty rate previously (1%-2%)Good date - high casualty rate previously (more than 2%)First event - No Date

Expected Numbers
---less than 1000less than 3000less than 5000less than 10,000less than 20,000less than 30,000less than 40,000less than 60,000less than 80,000less than 100,000less than 200,000less than 300,000

Expected Queuing
---less than four hoursMore than four hoursmore than twelve hours

Time of Year
---SummerAutumnWinterSpring

Proximity to definitive care (A&E)
---Less than 30 minutes by RoadMore than 30 minutes by Road

Profile of definitive care
---Choice of A & E departmentsLarge A & E DepartmentSmall A & E Department

Additional Hazard's
---NoneCarnivalHelicoptersMotor SportsParachute DisplaysStreet Theatre

Section 3 - Additional Information

Please let us know any other information which can support your risk assessment which can include other measures for example (for example if you are holding a fireworks display which a registered fireworks company has been contracted to carry out and will submit their own risk assessment, please let us know here.)

Section 4 - Please provide a brief summary of your event

Please provide a brief summary of your event for example "Our community event is aimed at families and has a range of stalls including food and crafts. There will be activities throughout the day in the main arena and music playing on a stage".

Section 5 -Addition provisions for your event

We would like to request an Ambulance at my event

---YesNo

We would like to request a Mobile Treatment Centre at my event
---YesNo

We would like to request a Medical Centre Gazebo at my event
---YesNo

We would like to request a Rapid Response Vehicle at my event
---YesNo

The event will require a 4x4 ambulance / response vehicle
---YesNo

We would like to request wound closure facility at the event
---YesNo

There is a room/building Ice Blue Medical can use as a treatment area/base
---YesNo

Section 6 - Billing Information

In this section, please let us know if the accounts contact information is the same as above or if we need to send it to a different person.

Is the details above the same for billing?
---YesNo

If "NO", Please complete the following:

Company Name:

Invoicing Address:

Reference number:

Accounts email address:

Accounts Contact Number:

Section 7 - Next steps

Using the information that you have supplied, Ice Blue Medical will e-mail you a quotation and review your assessment within the next five working days. We may need to contact you for further information. Please note that this form does NOT confirm a booking and does NOT confirm a contract to provide support at your event. Once we confirm your booking, Ice Blue Medical will require copies of the following documentation before we can provide any cover:

1 - Map of the Event
2 - Copy of your Event Risk Assessment
3 - Copy of your Event Action Plan