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
Club Member Details:
Name:
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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)
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Cause of Injury:
What led up to injury?
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How exactly was the injury occurrence caused?
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Is this a new injury or re-occurrence of a previous injury?
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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.
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Club Member’s Signature: ……………………………………
Date: ……../……../……..
Trainer in Charge Signature: …………………………………….
Date: ……../……../……..
Please add notes if appropriate:
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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 _____________________________________________________________________
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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? ………………………………………………………….………………………
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How exactly was the Incident caused? ………………………………………………………
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Notifications:
Has the head dojo instructor or President/Management Committee been notified? Yes/No
If so give details:
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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.
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Suggested short-term corrective action(s):
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Suggested long-term corrective action(s):
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Please add further notes/comments if appropriate:
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Club Member’s Signature (Person Reporting Incident/Completing Form):
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Date: ……../……../……..
Please add further notes/comments if appropriate:
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Instructor in Charge Signature: …………………………………….
Date: ……../……../……..