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INCIDENT AND INJURY REPORT
Fitness Focus Dubbo incident and injury report
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Email
*
Your email
Date of incident
*
MM
/
DD
/
YYYY
Time of incident
*
Time
:
AM
PM
Exact site location where incident occurred
*
Your answer
A. DETAILS OF INJURY AND TREATMENT
eg - to a worker or visitor.
Please fill in either A. DETAILS OF INJURY AND TREATMENT or B. DETAILS OF INCIDENT
Nature of incident
Near miss
First aid
Medical treatment needed
Clear selection
Name of injured person
Your answer
Date of birth of injured person
MM
/
DD
/
YYYY
Contact number of injured person
Your answer
Activity in which the person was engaged at the time of injury
Your answer
Nature of injury - eg fracture, burn, sprain ect
Your answer
Body location of injury - eg front or back, left or right, part of body ect
Your answer
Treatment given on site
Your answer
Name of treating person
Your answer
Referral for further treatment
Yes
No
Clear selection
Witness 1 to incident name
Your answer
Witness 1 to incident contact number
Your answer
Witness 2 to incident name
Your answer
Witness 2 to incident contact number
Your answer
B. DETAILS OF INCIDENT
- eg to property, plant or environmental damage
A. DETAILS OF INJURY AND TREATMENT or B. DETAILS OF INCIDENT
Description of incident
Your answer
Immediate response actions (eg barricades, isolation of power ect, warning signs ect) to stabilise the situation
Your answer
INCIDENT REPORTED TO
*
Provide details including name, time and form of communication
Your answer
FORM COMPLETED BY
*
Your answer
Send me a copy of my responses.
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