Incident Report Details
Please fill in the form below.
Venue Incident Occurred
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Bellbowrie Pool,47 Birkin Rd
Bundamba Pool, 256 Brisbane Rd
Carole Park Pool, Cnr Boundary & Waterford Rd
Goodna Gym, 6 Layard St
Goodna Pool, 137 Brisbane Tce
Leichhardt Pool,21 Toongarra Rd
Musgrave, 100 Edmondstone St
Orion Lagoon, 155 Southern Cross Circuit
Redbank Gym, 235 Smiths Road
Ripley Splash,Providence South Ripley
Riverheart Splash, 20 Bremmer Street
Rosewood Pool, Mill St
Tenterfield Pool
Valley Pool, 432 Wickham St
Lowood Pool, Main Street
Kilcoy Pool, Hope St & Mary St
Person Completing Report
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First Name
Last Name
Person Completing Report Email
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Please enter the venue email above - not personal
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Person Injured
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First Name
Last Name
Sex
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Female
Date of Birth
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Phone Number
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Area Code
Phone Number
Address
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Street Address
Street Address Line 2
City
State
Zip Code
If Under 18 Parent/Guardians
First Name
Last Name
Phone Number
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Area Code
Phone Number
Is the patient
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Member
Casual Guest
Employee
Contractor
Other
Upload Photo of area - include any relevant signs, safety warnings, hazards that caused the incident etc.
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The Incident
The incident was
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Injury
Alleged Assult
Alleged Theft
Dangerous Event
WHS Incident
Other
If injury please state type of injury and bodily location
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Description of incident - Detailed description. Include time, how the incident occurred and factors that may have contributed.
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Location inside venue - give as much detail as possible
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Workplace Health & Safety Incident
Was the correct PPE being worn
Yes
No
If Yes, describe in detail what was being worn/used
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The Treatment / Response
Explain in detail the treatment given to the patient.
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Include staff involved, public involved, pool closures, etc.
Did staff follow DRSABCD?
Yes
No
Was Oxygen Administered?
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Yes
No
Therapy
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Was the emergency services called?
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Police
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Manager
Have you notified general manager?
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No
Time Notified
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Council Notified
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