"Incident Report Form"

ADVERTISEMENT
Attachment 4: SAMPLE Incident Report Form
Please print clearly and tick the correct box
Status:
Participate
Coach
Volunteer
Parent
Sibling
Contractor
Other__________
Outcome:
Hazard only
Incident with no
Injury
Illness
injury/illness
Damage
Other________
1. DETAILS OF PERSON INVOLVED
Name: ________________________________________________ Phone: (H)
(W)
Address: ______________________________________________________ Sex:
M
F
_____________________________________________________________ Date of birth: ____________________________
_____________________________________________________________ Position: ________________________________
Experience in role: ______________________________________________ (years/months)
Arrival time: ____________________________________________________
am
pm
2. DETAILS OF INCIDENT
Date: _________________________
Time: __________________________________
Location: ______________________________________________________________________________________________
Describe what happened and how: __________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
3. DETAILS OF WITNESSES
Name: _______________________________________________________ Phone: (H) ______________ (W) ____________
Address: ______________________________________________________________________________________________
_____________________________________________________________________________________________________
4. DETAILS OF INJURY
Nature of injury (eg burn, cut, sprain) ________________________________________________________________________
Cause of injury (eg fall, grabbed by person) ___________________________________________________________________
Location on body (eg back, left forearm) _____________________________________________________________________
Agency (eg lounge chair, another person, hot water) ____________________________________________________________
5. TREATMENT ADMINISTERED
First Aid given
Yes
No
First Aider name: ________________________________________________________________________________________
Treatment: _____________________________________________________________________________________________
Referred to: ____________________________________________________________________________________________
Attachment 4: SAMPLE Incident Report Form
Please print clearly and tick the correct box
Status:
Participate
Coach
Volunteer
Parent
Sibling
Contractor
Other__________
Outcome:
Hazard only
Incident with no
Injury
Illness
injury/illness
Damage
Other________
1. DETAILS OF PERSON INVOLVED
Name: ________________________________________________ Phone: (H)
(W)
Address: ______________________________________________________ Sex:
M
F
_____________________________________________________________ Date of birth: ____________________________
_____________________________________________________________ Position: ________________________________
Experience in role: ______________________________________________ (years/months)
Arrival time: ____________________________________________________
am
pm
2. DETAILS OF INCIDENT
Date: _________________________
Time: __________________________________
Location: ______________________________________________________________________________________________
Describe what happened and how: __________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
3. DETAILS OF WITNESSES
Name: _______________________________________________________ Phone: (H) ______________ (W) ____________
Address: ______________________________________________________________________________________________
_____________________________________________________________________________________________________
4. DETAILS OF INJURY
Nature of injury (eg burn, cut, sprain) ________________________________________________________________________
Cause of injury (eg fall, grabbed by person) ___________________________________________________________________
Location on body (eg back, left forearm) _____________________________________________________________________
Agency (eg lounge chair, another person, hot water) ____________________________________________________________
5. TREATMENT ADMINISTERED
First Aid given
Yes
No
First Aider name: ________________________________________________________________________________________
Treatment: _____________________________________________________________________________________________
Referred to: ____________________________________________________________________________________________
SECTION 6-9 MUST BE COMPLETED BY CLUB OFFICIAL
6. DID THE INJURED PERSON STOP ACTIVITY?
Yes
No
If yes, state date: _____________________________ Time: _____________________
Outcome:
Treated by doctor
Hospitalised
Returned to normal activity
Alternative activity
Rehabilitation
7. INCIDENT INVESTIGATION (comments to include causal factors):
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
8. RISK ASSESSMENT
Likelihood of recurrence: __________________________________________________________________________________
Severity of outcome: _____________________________________________________________________________________
Level of risk: ___________________________________________________________________________________________
9. ACTIONS TO PREVENT RECURRENCE
Action
By whom
By when
Date completed
10. ACTIONS COMPLETED
Signed (Club Official): ____________________________________________________ Title:
Date: __________________________
Feedback to person involved
Signed (person involved): ________________________________________
Date: __________________________
11. REVIEW COMMENTS
Committee meeting: _____________________________________________________________________________________
Reviewed by Member Group Chairperson or Member Group Head Coach
(signed): ______________________________________________________________ Date: __________________________

Download "Incident Report Form"

211 times
Rate
4.6(4.6 / 5) 12 votes
ADVERTISEMENT
Page of 2