Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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STRICTLY PRIVATE & CONFIDENTIAL
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Date/Time
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Session
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Ice Rink
IP Personal Details
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Name
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Address
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Telephone Number
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Mobile Number
Incident Reporters Details
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Name
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Address
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Telephone Number
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Mobile Number
Incident Details
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Please give a detailed account of the accident in mention as well as any injuries that have occurred as a exult of this incident
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What if any treatment was given given and by whom
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What the IP advised to seek further medical attention?
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Was the IP taken to hospital? If so how?
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Please sketch a quick outline of where the accident took place
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Weather at time of incident (Take a picture which displays the current weather conditions.)
Declaration from IP
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I have read and understood the above report
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Signed:
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Signature of Parent/Guardian if IP is under 16
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Signed:
Information log
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Secondary report from first aider?
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Incident marked on the daily diary?
Skates / equipment.
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Skate Number.
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Was all equipment in use of a satisfactory condition? Skates sharp and structurally sound? Laces in tact? Blades in good condition?
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Notes on any additional equipment.
Photos.
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Picture of area where incident took place.
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Picture of rink from position 1
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Picture of rink from location 2
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Picture of equipment / skates
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Picture of equipment / skates 2
Chiller logs - this information should be taken from the ice technician hourly check sheet.
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Chiller temperature log
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Chiller 1 : Set point
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Chiller 2 : Set point
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Incoming refrigerant temperature Chiller 1:
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Incoming refrigerant temperature Chiller 2:
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Outgoing refrigerant temperature Chiller 1:
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Outgoing refrigerant temperature Chiller 2:
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Ambient temperature
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Please take an accurate ambient temperature reading from the thermometer located outside skate exchange
Incident Reporter Declaration
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I have completed this report to the best of my knowledge and all of the information I have submitted is correct.
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Signed:
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Date/Time
