Body Smart Health Incident / Accident Report

• Conducted on

  Date

• Prepared by

• Location

  Select

Person Impacted

• Date and time of incident

  Date

• Who was the person affected, injured or impacted?

  Select Client Visitor (Support person, other family member etc) Service provider (contractor, cleaner etc) Employee (including students, volunteers, employees)

  • Client
  • Visitor (Support person, other family member etc)
  • Service provider (contractor, cleaner etc)
  • Employee (including students, volunteers, employees)

• Persons Full Name

• Persons Date of Birth

• Persons Email Address

• Persons Mobile or Other Phone

Location of Incident

• Where did the incident occur?

  Select Body Smart Health Clinic At an external service provision location - gym, pool etc Clients home Medical Centre Other

  • Body Smart Health Clinic
  • At an external service provision location - gym, pool etc
  • Clients home
  • Medical Centre
  • Other

• Address where the incident occurred?

• Please add any additional information on the location of the incident?

Incident Details

• Type of Incident

  Select First Aid - Minor First Aid - Major Medical Episode - Minor Medical Episode - Major Behavioural - Physical or Verbal Agression Child safety Issue Security or Property Event Other

  • First Aid - Minor
  • First Aid - Major
  • Medical Episode - Minor
  • Medical Episode - Major
  • Behavioural - Physical or Verbal Agression
  • Child safety Issue
  • Security or Property Event
  • Other

• Details of Incident

• Please upload any files, photos or videos to assist with information capture

  Media

Actions Taken

• What actions were taken as a result of the incident?

  Select First aid provided Emergency services contacted Contacted NOK or emergency contact Advice and education provided Contacted doctor or other medical professional Other

  • First aid provided
  • Emergency services contacted
  • Contacted NOK or emergency contact
  • Advice and education provided
  • Contacted doctor or other medical professional
  • Other

• Please describe the specific details of the actions taken as a result of the incident

• Are additional actions required to eliminate future repeats of the incident?

• Is follow up required with the impacted person?

  Yes

  No

Other Parties / Witness

• List any witnesses or other parties here. Please include their full name, relationship (if any to the impacted person) and all contact details including phone and email information.

Sign Off

• Reporting persons name

• Position held

• Contact phone number

• Signature

  Sign