General Incident Report
RSG Arenas at Bridgewater - 1425 Frontier Road, Bridgewater, NJ 08807 - To report an incident, please provide the following information:
Date and time incident was reported:
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Date and time when incident actually occurred:
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Who was the main person involved in the incident/injured?
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Was there anyone else involved in the incident/injured?
*
Please Select
Yes
No
If yes, you will need to fill out a separate form for each injured person.
Who else was involved/injured? Add their Name, Age, & Phone Number
*
Please provide Incident details
*
Did the incident occur on the ice?
*
Please Select
Yes
No
Incident Location (if the incident took place on the rink, please indicate where it occurred by drawing an "X" below.
*
Type of ice cut
*
Please Select
Wet
Dry
N/A
Ice Resurface Time
*
Hour Minutes
AM
PM
AM/PM Option
Type of skate used:
*
Please Select
Own
Rental
N/A
Medical Section
Was First Aid Or Any Medical Supplies Provided?
*
Please Select
Yes
No
N/A
Who Administered The First Aid or Provided Medical Supplies?
*
Please Select
RSG-Employee
Non-RSG Employee
Both
Helper Name #1 - OPTIONAL
First Name
Last Name
Helper Phone Number #1 - OPTIONAL
Please enter a valid phone number.
Format: (000) 000-0000.
Helper Name #2 - OPTIONAL
First Name
Last Name
Helper Phone Number #2 - OPTIONAL
Please enter a valid phone number.
Format: (000) 000-0000.
Type of First Aid Administered, Including Medical Supplies Provided:
*
If you don't know, say "Don't Know".
Why wasn't any First Aid or Medical Support Proviided:
*
If you don't know, say "Don't Know". Did person "decline'? Or "no supplies available"
Was the injured person taken to the hospital?
*
Please Select
Yes
No
To what hospital?
*
If the injured refuses medical attention and/or 911, please have them or a legal guardian sign below.
Do you wish to add a picture?
Browse Files
Drag and drop files here
Choose a file
Cancel
of
RSG Waiver Information (mark all that apply)
*
Yes, the Release of Liability/Waiver was signed at the front desk.
Yes, the individual has a waiver on file in DASH.
Yes, the individual was wearing a waiver wristband.
No to all the above.
List details from any witness & include contact details.
*
Were the police notified?
*
Please Select
No
Yes, but they never came to the rink.
Yes, they came to the rink.
Did the Police give you a case or report number?
*
Please Select
Yes
No
Enter the Police Case or Report Number
*
Was a report of this incident you just filled out given to anyone else? If yes, who?
*
Person is who reporting this incident?
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Further General Comments
*
Report Now!
Should be Empty: