Incident Report
Program
*
Aktive Kidz
Adults
Holiday Program
GymNinja
GymStar
MAG
Open Session
TeamGym
Trampoline
Tumbling
WAG
School
Cheerleading
Inclusion
Dance
Other
Area of Facility
*
Air PIT
Beams
Cafe
Carpark
Fitness Equipment
Floor
Parkour
Hallway
Single Bars
Kitchen
Parallel Bars
Parkour Outside
PIT
Pommels
Reception
Rings
Toilets
Trampolines
Uneven Bars
Upstairs Viewing
Vault
Studio
Stairs
Seating
Red Floor
Rod Tumble Floor
Other
Incident
*
Aggression
Bullying
Equipment
Injury
Near Miss
Property Damage
Other
Date
*
/
Day
/
Month
Year
Date
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
Responding Staff
*
Barnes, Fiona
Barrington, Teagan
Blake, Dylan
Blunden, Lana
Cuerva, Al
Geddes, Hugh
Handreck, Heather
Hartwig, Digby
Haynes, Poppy
Joson, Vivien
Kennedy, Olivia
Mahal, Mikah
McCoy, Miriam
Panosh, Abbey
Pennell, Ben
Pennell, Don
Pennell, Heather
Pennell, Tom
Pennell, Lilly
Rosicka, Noah
Saunderson, Luke
Shannon, Mikala
Smith, Zarli
Taylor, Georgia
Thorp, Chelsea
Wright, Jonah
Staff Supervising
*
Barnes, Fiona
Barrington, Teagan
Blake, Dylan
Blunden, Lana
Cuerva, Al
Geddes, Hugh
Handreck, Heather
Hartwig, Digby
Haynes, Poppy
Joson, Vivien
Kennedy, Olivia
Mahal, Mikah
McCoy, Miriam
Panosh, Abbey
Pennell, Ben
Pennell, Don
Pennell, Heather
Pennell, Tom
Pennell, Lilly
Rosicka, Noah
Saunderson, Luke
Shannon, Mikala
Smith, Zarli
Taylor, Georgia
Thorp, Chelsea
Wright, Jonah
Attending Staff
*
Barnes, Fiona
Barrington, Teagan
Blake, Dylan
Blunden, Lana
Cuerva, Al
Geddes, Hugh
Handreck, Heather
Hartwig, Digby
Haynes, Poppy
Joson, Vivien
Kennedy, Olivia
Mahal, Mikah
McCoy, Miriam
Panosh, Abbey
Pennell, Ben
Pennell, Don
Pennell, Heather
Pennell, Tom
Pennell, Lilly
Rosicka, Noah
Saunderson, Luke
Shannon, Mikala
Smith, Zarli
Taylor, Georgia
Thorp, Chelsea
Wright, Jonah
First Aid
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Injured
First Name
Last Name
Date Of Birth
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
Year
Gender
Female
Male
Other
Activity Period
Training
Competition
Viewing
Other
Reported Symptoms
Blisters
Blood Nose
Bruising/Contusion
Burn
Cardiac Problem
Concussion
Cut/Laceration
Discolouration
Dislocation
Electrical Shock
Fracture/Break
Graze/Abrasion
Heavy Bleeding
Inflammation/Swelling
Insect Bite/Sting
Loss of Conciousness
Open Wound
Pain
Poisioning
Respiratory Problem
Spinal
Sprain/Strain
Stomach Pain
Tenderness
Other
Pain Rating
1
2
3
4
5
6
7
8
9
10
1 Star being least to 10 being worst pain
Injured Area
Pain Rating
1
2
3
4
5
6
7
8
9
10
1 Star being least to 10 being worst pain
Injured Area
Pain Rating
1
2
3
4
5
6
7
8
9
10
1 Star being least to 10 being worst pain
Injured Area
Back
Next
How Did The Injury Occur
Collision with fixed object (e.g. vault)
Collision with another person
Fall from height
Awkward landing
Fall/Stumble on same level (e.g. mats)
Over balance
Over stretch
Slip / Trip
Other
Explain How The Injury Occurred
Was Protective Equipment Being Worn/Used
Yes
No
Follow Action Required
No Referral
Ambulance
Hospital
Medical Practitioner
Private Transport
X-Rays
Other
Submit
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