INCIDENT / INJURY REPORT FORM
To be completed for ALL incidents, injuries, accidents and near misses
Today's Date
*
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Day
-
Month
Year
Date
Status:
*
Please Select
Employee
Official
Referee
Volunteer
Spectator
Contractor
Player
Details of injured person:
*
Surname
First Name
Date of Birth
Sex
Phone Number
Address
Details of witness:
Witness 1: Name
Witness 1: Phone
Witness 2: Name
Witness 2: Phone
Details of incident or accident :
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Date of injury
Time of injury
Activity engage in
Location of incident / accident
Drescribe how and what happened:
*
Please provide full details
Details of injury:
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Nature of injury / illness (e.g burn, sprain, cut)
How (e.g fall, slip, muscular stress)
Location on body (e.g back, right thumb, left arm)
What (e.g furniture, another person, hot water)
Treatment administered:
*
First Aid Administered (yes or no)
Treatment given (please outline)
Refereed to:
Incident or accident investigation:
Comments to include identified causal factors
Remedial actions:
What, in your own words, has been implemented or planned to prevent recurrence
Name of person writing report:
First Name
Last Name
Signature of person writing report:
Submit
Should be Empty: