INCIDENT REPORT CARD

INCIDENT DETAIL:

• Venue: Stadium

• Date / Time of Incident:

  Date

• Date / Time of Incident Reported

  Date

• Reported:

  In Person

  By Person

  In Writing

• Description of Incident:

• Exact Location of Incident:

• Photo of location:

  Media

Privacy Statement Acknowledgement:

• Personal Information collected on this card is used by < - > for the purpose of investigating this incident, including insurance, legal and risk based assessments and for reporting and statistical purpose. < - > may disclose the personal information collected on this card to third parties to achieve these purposes.

• Acknowledged by injured person:<br>(Staff member completing form to tick)

  Yes

  No

Injured Party

• Name:

• Address:

• Contact Number:

• Identify Injuried Party

  Visitor

  Contractor

  Staff

• Age:

• Gender:

  Male

  Female

• Footwear:

Witness:

• Was there an Witness:

  Yes

  No

• Name:

• Address:

• Contact Number:

Injury:

• Injury (specific body part) / Property damage (approx. value): Describe:

• Medical attention required:

  No

  Yes - Attach First Aid Report

CCTV:

• Was the Incident recorded on CCTV?

  Yes - Retain copy of Footage

  No

Cause:

• Injured person's explanation:

  Spillage

  Slip/Trip Hazard

  Other

• If spillage, name of cleaner on duty:

• Any warning / hazard signs in place?

  Yes

  No

• Mats in place?

  Yes

  No

• Last time area cleaned / Inspected prior to incidental:

  Date

Site Conditions:

• Lighting:

  All operational

  Not fully operational

• Weather:

  Select Wet Dry Bright Dark

  • Wet
  • Dry
  • Bright
  • Dark

• Steps:

  Internal

  External

• Any other parties Involved? <br><br>Eg. Tenant, contractor, cleaner etc.

  Yes

  No

• If yes, who?

• Floor type:

  Terrazzo

  Carpet

  Tiles

  Paved

  Other

• Comments:

• Name of staff completing card:

• Date:

  Date

• Sign:

  Sign

• Name of Supervisor: