Incident Form - Gym Services

Incident From - World Gym Burpengary

Date of Incident*

Details of Incident*

Other - Please describe:

Time of Incident*

:

NAME OF PERSON COMPLETING THIS FORM*

Person completing the Form*

Phone Number*

Location of Incident*

Full Name/s of Injured Person OR Person of Interest

Please use this section to enter in the name and contact number of anyone injured or people in interest in this incident:

Contact Phone Number of Injured Person/s*

Person of Interest*

WITNESS/ES OF INCIDENT:

If there was any witness/ed to the incident, please compelete the witness name and best contact number

Best Contact Number

WITNESS/ES OF INCIDENT:

If there was any witness/ed to the incident, please compelete the witness name and best contact number

Best Contact Number

Please give detailed description of the Incident or event:*

Please indicate where the injury occured (from the diagram)

Other - please describe area:*

WAS MEDICAL ASSISTANCE REQUIRED*

IF YES, HOW WAS INJURY TREATED?:

Name of the Person who applied First Aid:

AMBULANCE CALLED:

:

If an Ambulance was called - what time....

Please provide the name and contact number of the Person who called the Ambulance.

Please use this section for any further information that applies to this accident/incident:

Consent - I understand by signing name and pressing submit, that the information is true and correct.*

I agree/undestand

Enter Name*

Signature

Enter Name

Signature

All Comments will be treated with confidentiality and taken into consideration when planning changes to our Club. We appreciate your feedback

World Gym Burpengary | 159-161 Station Road, Burpengary Q 4505 | P 3053 3170 | E: reception@worldgymburpengary.com.au

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