Witness Statement - Incident Report
Gymnastics NSW
If a witness is a child under the age of 18, parent / guardian details must be provided.
Report File Number
Unique number on top of Incident Report
Date when incident occurred
/
Day
/
Month
Year
Date
Incident:
Gymsport injured person was primarily involved with at time of injury:
Please Select
Acrobatics
Aerobics
FreeG
GfA
Men's Artistic
Rhythmic
TeamGym
Trampoline
Women's Artistic
Incident Location:
e.g. name of venue
Specific area at location where the incident occurred:
Witness
First Name
Last Name
Witness's Role / Position
e.g. athlete, athlete's coach, coach, official, judge, etc.
Is the Witness under 18?
Yes
No
Witness Phone Number
Please enter a valid phone number. For a witness under the age of 18, please provide Parent / Guardian details.
Witness's Parent/Guardian Phone Number
Please enter a valid phone number. For a witness under the age of 18, please provide Parent / Guardian details.
Witness Email
example@example.com; For a witness under the age of 18, please provide Parent / Guardian details.
Witness's Parent/Guardian Email
example@example.com; For a witness under the age of 18, please provide Parent / Guardian details.
Witness Statement
Describe what happened. Use the full name of all people involved. If necessary, sketches, drawings and relevant photos and any other documents can be uploaded after the description below.
Files, photo and document uploads:
Browse Files
Drag and drop files here
Choose a file
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of
Witness Signature
Date
/
Day
/
Month
Year
Date
Save
Submit
Should be Empty: