Event Information Questionnaire 1 2 3 4 5 Dear Organiser Thank you for contacting the Northern Ireland Ambulance Service HSC Trust about your proposed event. To enable us to determine the best way to support you in the safe running of your event we need to seek some further information. 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. If you need to discuss any aspect of the questionnaire, please contact firstname.lastname@example.org in the first instance. 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 DetailsEvent Organiser Name* First Last Address Street Address Address Line 2 City County Postcode PhoneEmail* Event DetailsName/Title of Event*Start Date of Event* End Date of Event* Start TimePlease use 24 hour clock format for all times e.g. 8am = 08:00, 8pm = 20:00 HH : MM End TimePlease use 24 hour clock format for all times e.g. 8am = 08:00, 8pm = 20:00 HH : MM Location of Event* Postcode (if available) Other Event Sites (if appropriate) Type of Event*E.g. concert, agricultural show, motor sport, festival etcNumbers Expected*Additional RisksE.g. carnival, helicopters, alcohol on sale etc 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*Other Provision*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 DeputyEvent 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 Medical Provider or Nominated DeputyMedical 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 Please note that if this information is not available at the time of notifying NIAS of your event, please provide this information to email@example.com at the earliest possible opportunity. 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.