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Incident Report
Incident Report
Marketing & Communications
2022-04-12T16:23:25+10:00
Incident Report
Your information
The information of the person filling out the form. Whether or not you were directly involved in the incident itself.
Submitted by
*
Submitted by
First
First
Last
Last
Phone
*
Email
*
Incident – Part 1 of 7
Incident Type
*
Safety
Injury
Near Miss
Harassment
Security
Environment
Other
Other
Date
*
Location of Incident
*
Club
Yard
Marina
Beach
Other
Other
Type of Loss/Damage
*
Personal injury
Personal property
RMYS Property
Other
Other
Estimated Value ($) of Loss
*
Narrative – Part 2 of 7
Short description of what occured
*
Involved Person 1 – Part 3 of 7
Who is Person 1
*
Injured Person
Complainant
Witness
Other
Other
Relationship to site
*
Employee
Contractor
Member
Visitor
Public
Name
*
Name
First
First
Last
Last
Street, Suburb and Postcode
*
Phone
*
Statement
*
Signature
*
Clear
Date
*
Involved Person 2 – Part 4 of 7
Involved Person
Injured Person
Complainant
Witness
Other
Other
Relationship to Site
Employee
Contractor
Member
Visitor
Public
Name
Name
First
First
Last
Last
Phone
Signature
Clear
Date
Injury and/or Accident Information – Part 4 of 7
Nature of Injury
What tasks were occuring when the injury happened:
Was the incident reported to a supervisor/duty officer of the day?
Yes
No
Name of supervisor/duty officer
Emergency Response – Part 5 of 7
Signs and symptoms of injury
Treatment Required
N/A
First Aid
Referred to Doctor/Hospital
Taken by Ambulance
Refused Treatment
Other
Other
Description of First Aid Administered
Name of person administered First Aid
Name of person administered First Aid
First
First
Last
Last
Date of Administered
Time
12
1
2
3
4
5
6
7
8
9
10
11
:
00
30
AM
PM
Incident Resolution Action & Outcome – Part 7 of 7
Describe Action Taken
*
Relation to Club
*
Confirm Name
Confirm Name
First
First
Last
Last
Signature
Clear
Date
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