Incident Report Form 2024

Incident Report Form
INCIDENT REPORT FORM
Rowing SA will use this form to collect information and address incidents that have occurred, and those that constitute a potential future risk for the rowing community or the public.

Please use this form to report incidents and near misses pertaining to:
- on and off water events including, but not limited to, on water collisions or incidents, equipment damage/accidents at a Rowing SA site or venue
- breaches of Rowing SA Rules or Policies
- Member Protection complaints
- site hazards (e.g., exposed wires, broken decking)
There are 4 sections to this form. Please complete each section and attach any additional documentation (e.g., additional notes, photo's, statements) as required, or where the space provided is insufficient.

PLEASE NOTE: IF YOU ARE A RESIDENT, PLEASE COMPLETE THE RESIDENT INCIDENT FORM - FOUND HERE
1. Details Of Person Completing Report

Contact details

	Please complete all details
Full Name
Date of Birth
Email
Mobile phone

Were you involved in the incident?

YesNo
2. Incident Details
Did this occur at or during a regatta?

YesNo
Date of Incident

DayMonthYear
Date
Hour MinutesAM/PM Option
2a. Description of Incident
Location Incident occurred
Was this a medical or first aid incident?*

YesNo
Type of incident*
Minor injury details:

BruiseAbrasionStrainOther
Major injury details:

SprainFractureLacerationHead knockConcussionMedical conditionOther
Was an ambulance required?

YesNo
Was follow up treatment required?

YesNo
Description of Incident
please outline all information here
3. Incident (or Damage) Details
Please include as much detail as possible and attach additional pages as required.
Please provide any other relevant information here
Damage (Equipment) Details
File Upload for additional information where appropriate eg photos

Cancelof
3a. Witness Details

Please provide details of other individuals/witnesses involved where relevant
Witness 1 Name

First NameLast Name
Witness 1 phone pumber
Please enter a valid phone number.
Witness 2 Name

First NameLast Name
Witness 2 phone pumber
Please enter a valid phone number.
4. Follow Up Action
Please note Rowing SA may contact you for further information.
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
Date

DayMonthYear
Date
Signature

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Thank you for completing this report and helping Rowing SA keep the community safe.
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Incident Report Form

INCIDENT REPORT FORM

1. Details Of Person Completing Report

2. Incident Details

2a. Description of Incident

3. Incident (or Damage) Details

3a. Witness Details

4. Follow Up Action