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PICKLEBALL TOURNAMENTS AUSTRALIA First Report of Injury / Incident
To be used for reporting Major or Minor Injuries AND/OR Damage to Property/Others.
Event Name:
*
Name of Person Injured/ involved in Incident
*
First Name
Last Name
Reason for attending event:
*
Player
Volunteer
Staff
Visitor
Other
Time of Injury / Incident:
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Time Injury / Incident was Reported to Tournament director:
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Injury Reported to:
*
First Name
Last Name
Type of Incident:
*
Accident / Injury
Property Damage
Both Injury and Damage to property
Injury to Other (Customer)
Details of Incident(part of body/which equipment affected/how did it occur):
*
0/0
Witness(es) (If none, write "None"):
*
Phone Number of Witness:
Format: (000) 000-0000.
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First Report of Injury / Incident
Name of Customer Injured or Property Damaged:
First Name
Last Name
Phone # of Customer Injured or Property Damaged:
Format: (000) 000-0000.
Address Injury / Incident Took Place:
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
What person/substance/object caused the injury?
*
Safety Equipment that was required (if none, write "None"):
*
Safety Equipment that was used (if none, write "None"):
*
Was First Aid provided to Injured Person?
*
Yes
No
Refused
N/A (Property Damage only)
Injured Person was treated by:
*
EMS / Ambulance / First Responder
Emergency Room
First aid attendant
Urgent Care
N/A (Property Damage only)
Were the Police called (Property Damage)?
Yes
Refused by Customer
N/A
Estimated value of Damaged Property
Take photo of Injury / Damaged Property
Photo 2
Submit
Should be Empty: