APPENDIX A - ACCIDENT STATSTIC FORM

ACCIDENT STATISTIC FORM

APPENDIX A - HIGHLY CONFIDENTIAL
- To be completed by the CMO
- To be sent to the FIM at cmi@fim.ch
- To be strictly shared ONLY with: FIM MEDICAL DIRECTOR/OFFICER/DELEGATE/REPRESENTATIVE
1) EVENT INFORMATION
2) CHIEF MEDICAL OFFICER (CMO)

3) ACCIDENT STATISTIC

4) DATE

DayMonthYear
Date
The CMO, FIM Medical Representative, FIM Medical Director, FIM Medial Officer are bound to ensure that this Personal Data and sensitive Personal Data they process is protected as required by the data protection and privacy laws in force by applying all necessary security safeguards. This information shall not be disclosed to any other person except when strictly necessary in order to fulfil their obligations unde the FIM Medical Code and in accordance with art. 09.12
5) SIGNATURE OF CMO

Clear
Should be Empty:

ACCIDENT STATISTIC FORM