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FGPC & SWF Physical Incident Report Form
To be filled in after any physical incident involving FGPC/ SWF coaches, staff, or athletes. Most of the questions are marked as required, so fill in "N/A" if not applicable.
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* Indicates required question
*
MM
/
DD
/
YYYY
Time
:
AM
PM
Person Completing this form
Name
*
Name of person completing this report
Your answer
Phone Number
*
Phone number of person completing this report
Your answer
Email Address of person completing this form
*
Your answer
Injured or Affected Person
Name
*
Name of person injured or affected in the incident
Your answer
Job Title (if applicable)
Your answer
Birth Date
Birthday of injured or affected person
MM
/
DD
/
YYYY
Phone Number
*
Phone Number of injured or affected person
Your answer
Email Address of injured or affected person
*
Email address of injured or affected person
Your answer
Description of Incident
Type of incident
*
Collision
Grounding
Contact with debris
Theft/Vandalism
Other:
Required
Pre-incident
*
Your answer
Incident Description
*
Detailed description of incident, including identification of any unsafe conditions, acts or procedures which contributed in any manner to the incident .
Your answer
Weather Conditions
Wind and temperature if applicable
Your answer
Police
*
Were the police contacted?
Yes
No
Police Case Number
If police were contacted, what is the case number
Your answer
Ambulance
*
Was the ambulance called?
Yes
No
First Aid
*
Was first aid administered?
Yes
No
Injuries and treatment
*
Detailed description of injuries and treatment.
Your answer
First Aid attendant
*
Name and contact information for the person who administered First Aid
Your answer
Witnesses
*
Name and contact information of at least two witnesses to the incident.
Your answer
Damage
*
Detailed description of damage to property or equipment (if any)
Your answer
Action taken
*
Your answer
Corrective Action
*
Recommended corrective actions to prevent similar incidents
Your answer
Follow-up
Description of follow-up if applicable
Equipment Damage Resolved
Date of resolution (if applicable)
MM
/
DD
/
YYYY
Management Action Taken
Date of action taken (if applicable)
Your answer
Notes
Any additional information you find relevant
Your answer
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