Incident Report Form

Incident Report Form

Gymnastics NSW
Incident Report File Number - Office Use Only
Name of person submitting report

First NameLast Name
Date of Incident

DayMonthYear
Date
Role / Position / Title of person submitting report
Date of Report

DayMonthYear
Date
Gymsport incident primarily relates to:
Incident Information
Time Incident occurred:

Hour Minutes

AM/PM Option
Incident Type:
Incident Location:
e.g. name of venue
Specific area at location incident occurred:
Incident description

Brief description of incident. Describe the task, equipment, tools and people involved. Include any action taken to ensure the safety of those who may be affected. If necessary, sketches, drawings and relevant photos and any other documents can be uploaded after the description below.
Incident description:
Files, photo and document uploads:

Cancelof
Did the Incident involve an accident/injury?
Was first aid required?
Full name of injured person:

First NameLast Name
Injury Report File Number:
Unique number on top of Injury / Accident Report
Additional person injured?
Full name of second injured person:

First NameLast Name
Second Injury Report File Number:
Unique number on top of Injury / Accident Report
Additional person injured?
Full name of third injured person:

First NameLast Name
Third Injury Report File Number:
Unique number on top of Injury / Accident Report
Action Taken:
Describe what has been done to resolve the incident
Follow-up Action Required / Recommended:
Recommended action to fix hazard/incident. List any suggestions you may have for reducing or eliminating the problem – for example update procedures, improve training, maintenance work.
Additional Details:
Name / Role / Contact of Parties Involved

Person 1
Name

First NameLast Name
Role
Phone Number
Please enter a valid phone number. For a person under the age of 18, please provide Parent / Guardian details.Format: 0000 000 000.
Email
example@example.com For a person under the age of 18, please provide Parent / Guardian details.
Additional Party Involved:
Name / Role / Contact of Parties Involved

Person 2
Name

First NameLast Name
Role
Phone Number
Please enter a valid phone number. For a person under the age of 18, please provide Parent / Guardian details.Format: 0000 000 000.
Email
example@example.com For a person under the age of 18, please provide Parent / Guardian details.
Additional Party Involved:
Name / Role / Contact of Parties Involved

Person 3
Name

First NameLast Name
Role
Phone Number
Please enter a valid phone number. For a person under the age of 18, please provide Parent / Guardian details.Format: 0000 000 000.
Email
example@example.com For a person under the age of 18, please provide Parent / Guardian details.
Additional Party Involved:
Name / Role / Contact of Parties Involved

Person 4
Name

First NameLast Name
Role
Phone Number
Please enter a valid phone number. For a person under the age of 18, please provide Parent / Guardian details.Format: 0000 000 000.
Email
example@example.com For a person under the age of 18, please provide Parent / Guardian details.
Additional Party Involved:
Name / Role / Contact of Parties Involved

Person 5
Name

First NameLast Name
Role
Phone Number
Please enter a valid phone number. For a person under the age of 18, please provide Parent / Guardian details.Format: 0000 000 000.
Email
example@example.com For a person under the age of 18, please provide Parent / Guardian details.
Name / Role / Contact of Witnesses

Witness 1
Witness 1

First NameLast Name
Witness 1 Role / Position
e.g. athlete, athlete's coach, coach, official, judge, etc.
Witness 1 Phone Number
Please enter a valid phone number. For a witness under the age of 18, please provide Parent / Guardian details.Format: 0000 000 000.
Witness 1 Email
example@example.com; For a witness under the age of 18, please provide Parent / Guardian details.
Notes
Additional Witness
Name / Role / Contact of Witnesses

Witness 2
Witness 2

First NameLast Name
Witness 2 Role / Position
e.g. athlete, athlete's coach, coach, official, judge, etc.
Witness 2 Phone Number
Please enter a valid phone number. For a witness under the age of 18, please provide Parent / Guardian details.Format: 0000 000 000.
Witness 2 Email
example@example.com; For a witness under the age of 18, please provide Parent / Guardian details.
Notes
Additional Witness
Name / Role / Contact of Witnesses

Witness 3
Witness 3

First NameLast Name
Witness 3 Role / Position
e.g. athlete, athlete's coach, coach, official, judge, etc.
Witness 3 Phone Number
Please enter a valid phone number. For a witness under the age of 18, please provide Parent / Guardian details.Format: 0000 000 000.
Witness 3 Email
example@example.com; For a witness under the age of 18, please provide Parent / Guardian details.
Notes
Witness statements completed
Signature of person completing form
Date

DayMonthYear
Date
Should be Empty:

Incident Report Form

Incident Information

Incident description

Name / Role / Contact of Parties Involved

Name / Role / Contact of Parties Involved

Name / Role / Contact of Parties Involved

Name / Role / Contact of Parties Involved

Name / Role / Contact of Parties Involved

Name / Role / Contact of Witnesses

Name / Role / Contact of Witnesses

Name / Role / Contact of Witnesses