Sample Incident Report Form (Page 2 of 2) in pdf

Sample Incident Report Form Page 2

SECTION 6-9 MUST BE COMPLETED BY CLUB OFFICIAL

6. DID THE INJURED PERSON STOP ACTIVITY?

Yes

If yes, state date: _____________________________ Time: _____________________

Outcome:

Treated by doctor

Hospitalised

Returned to normal activity

Alternative activity

Rehabilitation

7. INCIDENT INVESTIGATION (comments to include causal factors):

_____________________________________________________________________________________________________

8. RISK ASSESSMENT

Likelihood of recurrence: __________________________________________________________________________________

Severity of outcome: _____________________________________________________________________________________

Level of risk: ___________________________________________________________________________________________

9. ACTIONS TO PREVENT RECURRENCE

Action

By whom

By when

Date completed

10. ACTIONS COMPLETED

Signed (Club Official): ____________________________________________________ Title:

Date: __________________________

Feedback to person involved

Signed (person involved): ________________________________________

Date: __________________________

11. REVIEW COMMENTS

Committee meeting: _____________________________________________________________________________________

Reviewed by Member Group Chairperson or Member Group Head Coach

(signed): ______________________________________________________________ Date: __________________________

Sample Incident Report Form Page 2