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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