ACG DRAFT ONLY | Internal Incident Report

Draft Only

To be reviewed by management
Internal Incident Report Details

Please fill in the form below.
Venue Incident Occurred*
Person Completing Report*

First NameLast Name
Person Completing Report Email*
Please enter the venue email above - not personal
Date*

DayMonthYear
Time

:HourMinutesAM/PM Option
Person Injured*

First NameLast Name
Sex*
Date of Birth*

DayMonthYear
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
If Under 18 Parent/Guardians

First NameLast Name
Phone Number

Area CodePhone Number
Is the patient*

MemberCasual GuestEmployeeContractorOther
Upload Photo of area - include any relevant signs, safety warnings, hazards that caused the incident etc. If you do not have the time to upload now then please send the photos to (yourfacilitymanager)@justsportsnfitness.com.au at your earliest convenience for them to attach to this incident report.

Browse Files

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The Incident
The incident was*

InjuryAlleged AssultAlleged TheftDangerous EventWHS IncidentOther
If injury please state type of injury and bodily location
Description of incident - Detailed description. Include time, how the incident occurred and factors that may have contributed. *
Location inside venue - give as much detail as possible*

The Treatment / Response
Explain in detail the action taken by staff.*
Include staff involved, public involved, pool closures, etc.
Did staff follow DRSABCD?*

Yes
Was Oxygen Administered?*
Therapy

:HourMinutesAM/PM Option
Until
until :HourMinutesAM/PM Option
Resuscitation

:HourMinutesAM/PM Option
Until
until :HourMinutesAM/PM Option
Was the emergency services called?*
If Yes

PoliceFireAmbulance
If Yes
Time Called

:HourMinutesAM/PM Option
Time Arrived

:HourMinutesAM/PM Option
Time Departed

:HourMinutesAM/PM Option

Internal Incident Report Details