Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • STRICTLY PRIVATE & CONFIDENTIAL

  • Date/Time

  • Session

  • Ice Rink

IP Personal Details

  • Name

  • Address

  • Telephone Number

  • Mobile Number

Incident Reporters Details

  • Name

  • Address

  • Telephone Number

  • Mobile Number

Incident Details

  • Please give a detailed account of the accident in mention as well as any injuries that have occurred as a exult of this incident

  • What if any treatment was given given and by whom

  • What the IP advised to seek further medical attention?

  • Was the IP taken to hospital? If so how?

  • Please sketch a quick outline of where the accident took place

  • Weather at time of incident (Take a picture which displays the current weather conditions.)

Declaration from IP

  • I have read and understood the above report

  • Signed:

  • Signature of Parent/Guardian if IP is under 16

  • Signed:

Information log

  • Secondary report from first aider?

  • Incident marked on the daily diary?

Skates / equipment.

  • Skate Number.

  • Was all equipment in use of a satisfactory condition? Skates sharp and structurally sound? Laces in tact? Blades in good condition?

  • Notes on any additional equipment.

Photos.

  • Picture of area where incident took place.

  • Picture of rink from position 1

  • Picture of rink from location 2

  • Picture of equipment / skates

  • Picture of equipment / skates 2

Chiller logs - this information should be taken from the ice technician hourly check sheet.

  • Chiller temperature log

  • Chiller 1 : Set point

  • Chiller 2 : Set point

  • Incoming refrigerant temperature Chiller 1:

  • Incoming refrigerant temperature Chiller 2:

  • Outgoing refrigerant temperature Chiller 1:

  • Outgoing refrigerant temperature Chiller 2:

  • Ambient temperature

  • Please take an accurate ambient temperature reading from the thermometer located outside skate exchange

Incident Reporter Declaration

  • I have completed this report to the best of my knowledge and all of the information I have submitted is correct.

  • Signed:

  • Date/Time

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.