Mitre 10 Sports Park Notification of Accident or Injury
Please ensure you fill this form out for all health and safety related issues
Registrant Details
Full Name
First Name
Last Name
Email
example@example.com
Particulars of Accident/incident
Name of person injured
First Name
Last Name
Contact Number
Please enter a valid phone number.
Date of Accident/Incident
-
Month
-
Day
Year
Date
Time of Accident/Incident
Hour Minutes
AM
PM
AM/PM Option
Date
-
Month
-
Day
Year
Date
Type of Injury
Please Select
Bruising
Dislocation
Break/Fracture
Bleeding/Scratch/Bruising
Internal injury
Strain/sprain
Any other comments
Location in Mitre10 Sports Park
Damaged Property
Property or material damage
Object/substance causing damage
The Accident/Incident
Please describe what happened
What caused the accident/incident?
How serious COULD it have been?
How likely is it to happen again?
Prevention - what action has or will be taken to stop another accident/incident happening again in the future?
Treatment
Type of treatment given
Name of person giving First Aid
Doctor/Hospital visited? (please include name)
Have Mitre10 Sports Park staff been advised?
Yes
No
Other
Should WorkSafe be advised?
Yes
No
Other
As part of your usage terms of conditions you are required to abide by the law and report any accidents or hazards immediately.
I accept these terms and conditions
Submit
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