05 Accident and incident forms

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05 Accident and incident forms

NOTE; We (Aikido Republic) now use the forms provided by the Australian Sports Commission (Why reinvent the wheel if you can use the best). Here is the link and a google search (if it moves location on the website)

Here are the Accident and Incident forms developed for Aikido Yuishinkai Australia

Accident Report Form

Club Member Details:

Name:

……………………………………………………………………………………………………

Address: ……………………………………………………………………………………………..……

Phone No.s: Home: …………….…...Mobile:……………...………Work:…………..….……

Accident Site:

Address of Accident: ………………………………………………………………...……………….…

Place of Accident: ………………………..………………………………………………….…..………

Date: ……../…..…/…..… Time: ……………………am/pm

Injury Details:

Type of Injury: ……………………………………………….…………………………….…………..

Was First Aid Applied? …………………………… By Whom? …….……………………………

Action After Injury (e.g. Doctor/Ambulance/Hospital)

……………………………………………………………………………………………………

Cause of Injury:

What led up to injury?

……………………………………………………………………………………………………

How exactly was the injury occurrence caused?

……………………………………………………………………………………………………

Is this a new injury or re-occurrence of a previous injury?

……………………………………………………………………………………………………

Notifications:

Has the Club President/Management Committee been notified? Yes/No (Please Circle)

Witness:

Where there witnesses to the injury? ………………………………………………………………….

Name of witness one: ……………………………………………………………………………………

Address: …………………………………………………………………………………………………

Phone No’s: Home: …………….…...Mobile:……………...………Work:…………..….……

Where there witnesses to the injury? ………………………………………………………………….

Name of witness Two: ……………………………………………………………………………………

Address: …………………………………………………………………………………………………

Phone No’s: Home: …………….…...Mobile:……………...………Work:…………..….……

Prevention:

Are you aware of any action that has been, or can be, taken to prevent the accident from happening again. If so give details.

……………………………………………………………………………………………………

Club Member’s Signature: ……………………………………

Date: ……../……../……..

Trainer in Charge Signature: …………………………………….

Date: ……../……../……..

Please add notes if appropriate:

……………………………………………………………………………………………………

Critical Incident Report Form

Type of Incident:

□ Incident involving a person (eg. work-related illness, near miss, dangerous event)

□ Incident only (e.g. theft, property loss/damage, environmental damage)

□ Hazard/Risk

□ Training Injury (Please use Accident Report Form)

□ Unsafe Activity

□ Allegation of Impropriety

□ Bullying/Harassment

□ Other

Have appropriate government agencies/services been notified/advice sought? (e.g. police, fire, doctor/hospital, environmental protection, children’s commissioner, etc.)

Name of the Contact Person _____________________________ Date ____________

Office Location _____________________ Phone No. _________________________

Club Member Details (Person Reporting Incident/Completing Form):

Name: ……………………………………………………………………..………………

Address: ……………………………………………………………………………………………..……

Phone No.s: Home: …………….…...Mobile:……………...………Work:…………..….……

Club Member Details (Person Involved in Incident – if applicable):

Name: ……………………………………………………………………..…………………

Address: ……………………………………………………………………………………………..……

Phone No.s: Home: …………….…...Mobile:……………...………Work:…………..….……

Club Member Details (Person Involved in Incident – if applicable):

Name: ……………………………………………………………………..………………

Address: ……………………………………………………………………………………………..……

Phone No.s: Home: …………….…...Mobile:……………...………Work:…………..….……

Incident Details:

Address of Incident: ………………………………………………………………...……………….…

Place of Incident: ………………………..………………………………………………….…..………

Date: ……../…..…/…..… Time: ……………………am/pm

Describe details of the Incident or hazard _____________________________________________________________________

_____________________________________________________________________

What there anything unusual or unexpected about this event?

Provide a sketch if helpful or significant

Cause of Incident:

What led up to the Incident? ………………………………………………………….………………………

…………………………………………………………………………….……………………

How exactly was the Incident caused? ………………………………………………………

………………………………………………………………….………………………………

Notifications:

Has the head dojo instructor or President/Management Committee been notified? Yes/No

If so give details:

…………………………………………………………………………………………

Witnesses:

Where there witnesses to the incident? ………………………………………………………………….

Name of witness one: ……………………………………………………………………………………

Address: …………………………………………………………………………………………………

Phone No’s: Home: …………….…...Mobile:……………...………Work:…………..….……

Name of witness Two: ……………………………………………………………………………………

Address: …………………………………………………………………………………………………

Phone No’s: Home: …………….…...Mobile:……………...………Work:…………..….……

Prevention/Corrective Action:

Are you aware of any action that has been, or can be, taken to prevent the incident from happening again (e.g. physical environment, equipment, awareness/behavioural, training, cultural, administrative changes). If so give details.

…………………………………………………………………………………………

Suggested short-term corrective action(s):

…………………………………………………………………………………………

Suggested long-term corrective action(s):

…………………………………………………………………………………………

Please add further notes/comments if appropriate:

……………………………………………………………………………………………………

Club Member’s Signature (Person Reporting Incident/Completing Form):

……………………………………

Date: ……../……../……..

Please add further notes/comments if appropriate:

……………………………………………………………………………………………………

Instructor in Charge Signature: …………………………………….

Date: ……../……../……..

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