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The Compound Club
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Participant Accident/Incident Report Form
This form is to be filled out by the participant or health and safety representative on behalf of the participant.
Participant's details:
Are you filling this form out on behalf of someone else?
Yes
No
Participant's name:
*
Please give the name of the person you are filling this form out for.
First
Last
Your Name
*
First
Last
Do you work at the same company?
Yes
No
Participant's job title:
*
Please give the job title of the participant. If you are unsure, please write 'unsure'.
Your job title:
*
Your Name
*
First
Last
Relationship
*
Please describe your relationship to the class participant this form relates to.
Please give the reason why you are filling out this form on behalf of the injured class participant.
*
Today's date:
*
Month
Day
Year
Incident Details
Did the incident occur today?
Yes
No
Incident date:
*
Month
Day
Year
Reason:
*
In as much detail as you can, please explain why this form was not completed on the same date as the incident.
Incident location:
*
Time of incident:
*
:
Hours
Minutes
AM
PM
Class Details
Class:
*
Please give the name of the class the incident took place. If you are unsure, please write 'unsure'.
Time:
*
What time was the class scheduled for?
:
Hours
Minutes
AM
PM
Time:
*
What time did you sign in to the class?
:
Hours
Minutes
AM
PM
Time:
What time did the participant arrive at the class? If you don't know, please move on to the next question.
:
Hours
Minutes
AM
PM
Instructor's name
*
Please give the name of the class instructor. If you are unsure, please write 'unsure'.
Accident/Incident Details
Please check the appropriate boxes. You may select more than one option.
Head & Face
Head
Face
Description:
*
Please describe where on the head the injury is:
Description:
*
Please describe the injury/s sustain on the face:
Neck & Torso
Neck
Upper back
Lower back
Chest
Abdomen
Pelvis / groin
Shoulders & Arms
Which Side did the injury take place?
Right
Left
Both
Where on the shoulders and/or arms is the injury/s?
*
Arm
Elbow
Wrist
Hand
Fingers
Hips & Legs
Which Side did the injury take place?
Right
Left
Both
Where on the hips & legs did the injury/s take place?
*
Hip
Thigh
Knee
Lower leg
Ankle
Foot
Toes
Accident/Incident Description
Description:
*
Please give your account of the incident to the best of your knowledge.
Further information:
Please give any further information regarding this incident.
Verification
Signature
*
Please sign here if you filled this form out on behalf of someone else.
Signature
*
Please sign here.
Email
If you would like a copy of this form emailed to you then please fill in your email address below.
Email
If you would like to send a copy of this email to the person you are filling out this form for, please write their email address below.
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