Incident Report Form
Gymnastics NSW
Incident Report File Number - Office Use Only
Name of person submitting report
First Name
Last Name
Date of Incident
/
Day
/
Month
Year
Date
Role / Position / Title of person submitting report
Date of Report
/
Day
/
Month
Year
Date
Gymsport incident primarily relates to:
Please Select
Acrobatics
Aerobics
FreeG
GfA
Men's Artistic
Rhythmic
TeamGym
Trampoline
Women's Artistic
Incident Information
Time Incident occurred:
Hour Minutes
AM
PM
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:
Browse Files
Drag and drop files here
Choose a file
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of
Did the Incident involve an accident/injury?
Yes
No
Was first aid required?
Yes
No
Full name of injured person:
First Name
Last Name
Injury Report File Number:
Unique number on top of Injury / Accident Report
Additional person injured?
Yes
Full name of second injured person:
First Name
Last Name
Second Injury Report File Number:
Unique number on top of Injury / Accident Report
Additional person injured?
Yes
Full name of third injured person:
First Name
Last 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 Name
Last Name
Role
Phone Number
Please enter a valid phone number. For a person under the age of 18, please provide Parent / Guardian details.
Email
example@example.com For a person under the age of 18, please provide Parent / Guardian details.
Additional Party Involved:
Yes
No
Name / Role / Contact of Parties Involved
Person 2
Name
First Name
Last Name
Role
Phone Number
Please enter a valid phone number. For a person under the age of 18, please provide Parent / Guardian details.
Email
example@example.com For a person under the age of 18, please provide Parent / Guardian details.
Additional Party Involved:
Yes
No
Name / Role / Contact of Parties Involved
Person 3
Name
First Name
Last Name
Role
Phone Number
Please enter a valid phone number. For a person under the age of 18, please provide Parent / Guardian details.
Email
example@example.com For a person under the age of 18, please provide Parent / Guardian details.
Additional Party Involved:
Yes
No
Name / Role / Contact of Parties Involved
Person 4
Name
First Name
Last Name
Role
Phone Number
Please enter a valid phone number. For a person under the age of 18, please provide Parent / Guardian details.
Email
example@example.com For a person under the age of 18, please provide Parent / Guardian details.
Additional Party Involved:
Yes
No
Name / Role / Contact of Parties Involved
Person 5
Name
First Name
Last Name
Role
Phone Number
Please enter a valid phone number. For a person under the age of 18, please provide Parent / Guardian details.
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 Name
Last 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.
Witness 1 Email
example@example.com; For a witness under the age of 18, please provide Parent / Guardian details.
Notes
Additional Witness
Yes
No
Name / Role / Contact of Witnesses
Witness 2
Witness 2
First Name
Last 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.
Witness 2 Email
example@example.com; For a witness under the age of 18, please provide Parent / Guardian details.
Notes
Additional Witness
Yes
No
Name / Role / Contact of Witnesses
Witness 3
Witness 3
First Name
Last 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.
Witness 3 Email
example@example.com; For a witness under the age of 18, please provide Parent / Guardian details.
Notes
Witness statements completed
Yes
No
N/A
Signature of person completing form
Date
/
Day
/
Month
Year
Date
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