Incident Report Form

Incident Report Form

Please use this form to report all incidents and near misses
INCIDENT REPORT FORM
Rowing SA uses this form to gather information about incidents that have occurred, as well as situations that may present a future risk to the rowing community or the public.

Please use this form to report first aid incidents, other incidents, and near misses relating to:
- On-water and off-water events, including (but not limited to) collisions, capsizes, or equipment damage at any Rowing SA site or venue
- Breaches of Rowing SA Rules, Policies, or Codes of Conduct
- Member Protection concerns or complaints
- Identified site hazards (e.g., exposed wiring, damaged decking, unsafe infrastructure)
This form contains several sections.

Please complete all relevant sections and attach any supporting documentation—such as additional notes, photographs, or witness statements—where required or where the space provided is insufficient.

PLEASE NOTE: IF YOU ARE A RESIDENT AND HAVE A RESIDENT SPECIFIC ISSUE, PLEASE COMPLETE THE RESIDENT INCIDENT FORM - FOUND HERE
Date of Incident
Date of Incident

DayMonthYear
Date
Hour MinutesAM/PM Option
Type of incident
Was this a medical or first aid incident?*

YesNo
Type of incident*
Did this occur at or during a regatta?*

YesNo
Details of Person Completing Report
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

CityState

Post Code
Phone Number
Please enter a valid phone number.
Were you involved in the incident?*

YesNo
Please provide the name and details of who was involved.
First Aid Incident
Injured person's details
Name of person receiving first aid

First NameLast Name
Gender

MaleFemaleUnspecified
Date of Birth if known

DayMonthYear
Date
Contact Details of injured person
Phone Number
Please enter a valid phone number.
Description of Incident
Minor injury details:

BruiseAbrasionStrainOther
Major injury details:

SprainFractureLacerationHead knockConcussionMedical conditionOther
Was an ambulance required?

YesNo
Was follow up treatment required?

YesNo
Where did the incident occur ie water, reserve, other location.
Activities of the person at the time of incident / Events leading up to incident
Full description of incident
please complete as many details as possible.
Describe the first aid treatment that was provided
Provide as much detail as possible.
Indicate below the area of the injury
Were there any witnesses*

YesNo
Incident (or Damage) Details
Location of where incident or damage occured*
Please include as much detail as possible and attach additional pages as required.
Please provide the full description of the incident with as much information you can provide
Damage (Equipment) Details if relevant
File Upload for additional information where appropriate eg photos

Cancelof
Witness Details

Please provide details of other individuals/witnesses who were involved or who can assist to confirm details, where relevant.
Person one Name

First NameLast Name
Person one phone number
Please enter a valid phone number.
Person two Name

First NameLast Name
Person two phone number
Please enter a valid phone number.
Follow Up Action
Please note:

Once a report is received, it will be reviewed by the RSA staff to determine the nature and seriousness of the issue raised and the action that is required to resolve the report.

All incidents are handled confidentially and assessed in accordance with organisational policies and procedures. Where necessary, further information may be sought from involved parties to ensure a fair and thorough response.

The matter will then be addressed appropriately.

RSA will ensure the reportee is kept informed of the process and advised of the outcome.
Would you like this report to be kept confidential?*

YesNo
Would you like to be contacted to discuss further action?*

YesNo
Would you like this report added to the incident register but do not require further contact?

YesNo
Please provide suggestions on how to improve practices.
Signature
Signature

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Date

DayMonthYear
Date
Thank you for completing this report and helping Rowing SA keep the community safe.
Should be Empty:

Incident Report Form

INCIDENT REPORT FORM

Date of Incident

Type of incident

Details of Person Completing Report

First Aid Incident

Injured person's details

Contact Details of injured person

Description of Incident

Incident (or Damage) Details

Witness Details

Follow Up Action

Signature