Incident Report

Incident Report

Melbourne Gymnastics Centre
This form must be completed as soon as possible after the occurance of an incident.

Complete with as much detail as possible. All incident reports must be securely stored.

Please submit once complete and the report will be emailed the the centre manager for followup within 24 hours.

If you believe a child is at immediate risk of abuse please phone 000
Name(s) of Athlete involved:*
Name of staff Member Involved:*
Date the incient occured:

MonthDayYear
Date
Time of Incident:*
Centre Location:*
Location of incident:(i.e. floor, bars, rings)*
Class Type/Time:*
Please categorise the incident:*

Physical violenceSerious IinjurySexual Offence/harassmentSerious emotional or physical abuse/harassmentSerious neglectMedical EmergencyMinor injuryUnacceptable behaviour
Please describe the incident (what did you see?) (What occurred?)
What immediate steps did you take to resolve the incident?
Other Information:
Does the athlete/staff member identify as Aboriginal or Torres Straight Islander?

NoYes AboriginalYes Torres Straight Islander
OFFICE USE ONLY

Centre Manager to complete
Date report received:
Team member following up incident
Follow up date/result:
Contributing factors to the incident:
What steps will be taken to limit risk in future?
Has the incident been reported?

Child ProtectionPoliceAnother third party (please specify below)Other
Should be Empty:

OFFICE USE ONLY