GYM Incident Report Form
GYM Incident Report Form
Type of Incident: Dangerous Occurrence Yes / No ______
Physical Injury Yes / No ______
Date: ______________________________ Time___________________________________________
Location: ____________________________________________________________________________
Details of injured person: Name ____________________ ldap: ___________________________
Name of person completing form: _____________________________
Describe the nature and details of the incident (including Injuries sustained):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
First Aid Provided or Remedial Action:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
___________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Firs Aid Treatment Provided (if any) and by whom:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Details of Witnesses:
Name ____________________________ Ldap __________________________________
Name ____________________________ Ldap __________________________________
................
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