Gym Incident Report Form
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Gym Incident Report Form
About the incident
Date of incident:
*
Time of incident:
*
Where did it happen? Please give specific details. Please provide location (e.g. Female Changing Room, Male Changing Room, Swimming Pool, Tanning Area, Cardiovascular Area etc.).
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What happened? Please describe the near miss, accident, incident, dangerous occurrence etc., including events that lead to it, and details about any equipment, substances or materials involved.
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Were there any witnesses? Name(s) and contact details of anyone who witnessed the incident.
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About the person(s) involved (if applicable)
Who was involved? Name, role and contact details (e.g. Staff Member, Club Member, Contractor). Please ensure you include the full name(s) and contact details for any parties injured.
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Were any injuries sustained?
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Yes
No
What type of injury / illness / disease has been sustained? Please include which part/side of the body was affected.
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What action was taken? (e.g. None, First Aid treatment by Staff, Referred to Doctor, Transported to hospital etc.)
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What treatment was provided? Please include whether first aid and/or hospital treatment was needed.
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Person completing this form
Details of the person completing this form. Name, role and contact details
*
Email:
*
Signature:
*
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Dancing Script
Sacramento
Alex Brush
Parisienne
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Dancing Script
Sacramento
Alex Brush
Parisienne
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