Cairns Basketball Incident Report Form
This form is to be completed for any incident, injury, behavioural issue, child safety concern, facility hazard, breach of policy, or other matter occurring during a Cairns Basketball activity. Information provided in this form will be treated confidentially and reviewed by Cairns Basketball Management.
Section 1 - Reporter Details
Name
First Name
Last Name
Role
Please Select
Staff Member
Coach
Team Manager
Referee
Volunteer
Parent/Guardian
Spectator
Participant
Other
Phone Number
Please enter a valid phone number.
Format: 0000 000 000.
Email
example@example.com
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Section 2 - Incident Details
Date of Incident
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Incident
Hour Minutes
AM
PM
AM/PM Option
Location
Please Select
Court 1
Court 2
Court 3
Court 4
Court 5
Stadium Foyer
Classroom
Canteen
Car Park
Meeting Room
Gym
Off-site Venue
Other
If other, please specify
Competition/Program
Please Select
Domestic Competition
Representative Program
NBL1 North
Mini Marlins & Dolphins
Skills Builders
School Program
School Holiday Camp
Moonlight Hoops
Other
If other, please specify
Section 3 - Person(s) Involved
Primary Person Involved
First Name
Last Name
Age (if under 18)
Role of Primary Person
Please Select
Participant
Coach
Referee
Parent/Guardian
Spectator
Team Manager
Staff Member
Volunteer
Other
Additional Persons Involved
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Section 4 - Incident Type
Type of Incident
Injury/Medical Incident
Child Safety Concern
Bullying
Harassment
Discrimination
Verbal Abuse
Physical Altercation
Threatening Behaviour
Referee Abuse
Spectator Misconduct
Breach of Code of Conduct
Property Damage
Facility Hazard
Theft
Social Media Misconduct
Other
Section 5 - Incident Description
Please describe exactly what occured. Include events leading up to the incident, what happened, and who was involved.
What was your involvement in the incident?
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Section 6 - Immediate Action Taken
Immediate Actions Taken
First Aid Provided
Emergency Services Contacted
Parent/Guardian Contacted
Participant Removed from Activity
Staff Member Notified
Police Contacted
No Immediate Action Taken
Other
Provide Details of Actions Taken
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Section 7 - Injury Details
(Only fill this section in if you selected "Injury/Medical Incident" in the previous section)
Was anyone injured?
Yes
No
Nature of Injury
Please Select
Minor
Moderate
Serious
Describe the Injury:
Was First Aid Provided?
Yes
No
First Aid Officer Name:
Was an ambulance called?
Yes
No
Section 8 - Child Safety Concern
(Only fill this section in if you selected "Child Safety Concern" in section 6)
Does this incident involve a child or young person under 18 years of age?
Yes
No
Nature of Concern?
Physical Harm
Emotional Harm
Neglect
Grooming Behaviour
Inappropriate Conduct
Breach of Child Safe Standards
Online Misconduct
Other
Details of Concern?
Has a parent/guardian been notified?
Yes
No
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Section 9 - Witnesses
Were there any witnesses?
Yes
No
Witness 1 Name
Witness 1 Contact Details
Witness 2 Name
Witness 2 Contact Details
Section 10 - Evidence
Evidence Available
CCTV Footage
Video Recording
Photographs
Screenshots
Written Statement
Social Media Post
None
Upload Evidence
Browse Files
Drag and drop files here
Choose a file
Allowed Files: JPG, PNG, PDF, DOCX, MP4 Maximum File Size: 20MB per file
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Section 11 - Follow-up
Do you believe further action is required?
Yes
No
Please explain why you believe further action may be required:
Section 12 - Declaration
I declare that the information provided in this report is true and accurate to the best of my knowledge.
*
I agree
Signature
Date Submitted
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
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