Sample Incident Report Form

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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: ____________________________________________________________________________________________

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