Incident Report

• Incident Date & Time

  Date

• Incident Title (eg. Rescue)

• Location

  Select Plunge Pool (Left) Plunge Pool (Right) Main Entry Change Rooms Staff Room Surf Academy Left Lagoon Right Lagoon Event Area (Lawns) Event Area (Retail - Changerooms) Event Area (Left Lagoon) Car Park Plant Room

  • Plunge Pool (Left)
  • Plunge Pool (Right)
  • Main Entry
  • Change Rooms
  • Staff Room
  • Surf Academy
  • Left Lagoon
  • Right Lagoon
  • Event Area (Lawns)
  • Event Area (Retail - Changerooms)
  • Event Area (Left Lagoon)
  • Car Park
  • Plant Room

DETAILS OF PERSON(S) INVOLVED IN INJURY OR INCIDENT

• Full Name (First & Last)

• Date of Birth (DOB)

  Date

• Is Person(s) under 16?

  No

  Yes

• Parent / Guardian Full Name

• Mobile Number

• Sex

  Male

  Female

  Other

• Contact Number

• Home Address

• Suburb

• State

  Select Victoria New South Wales Queensland Tasmania ACT Western Australia Northern Territory South Australia Overseas

  • Victoria
  • New South Wales
  • Queensland
  • Tasmania
  • ACT
  • Western Australia
  • Northern Territory
  • South Australia
  • Overseas

Incident Description

• Provide Detailed Incident Description Below (Who, What, When, Where, How?)

• Type of Incident

  Select Damage to Equipment / Property Vehicle Accident Theft Disorderly Conduct Request to Leave Pre - Existing Illness Blood Nose Bruising Cut Sprain / Strain Sting / Bite Allergic Reaction Burn Fainting Fracture Dislocation Eye Impairment Seizure Head Injury Poisoning Asthma Loss of Consciousness Concussion Breathing Difficulty Spinal Cardiac Complication Dental Other

  • Damage to Equipment / Property
  • Vehicle Accident
  • Theft
  • Disorderly Conduct
  • Request to Leave
  • Pre - Existing Illness
  • Blood Nose
  • Bruising
  • Cut
  • Sprain / Strain
  • Sting / Bite
  • Allergic Reaction
  • Burn
  • Fainting
  • Fracture
  • Dislocation
  • Eye Impairment
  • Seizure
  • Head Injury
  • Poisoning
  • Asthma
  • Loss of Consciousness
  • Concussion
  • Breathing Difficulty
  • Spinal
  • Cardiac Complication
  • Dental
  • Other

• Details of other (if selected)

• Upload Photo(s) (if required)

  Media

Incident Classification

• Read Incident Classification

  

• Select Incident Classification

  Select Near Miss Report Only Minor Major Catastrophic COVID-19

  • Near Miss
  • Report Only
  • Minor
  • Major
  • Catastrophic
  • COVID-19

• Is the Incident Major or COVID19 Related?

  No

  Yes

• Is the Incident Catastrophic?

  No

  Yes

• Was this a Rescue?

  No ( NO Rescue Conducted)

  Yes (Rescue Conducted)

• Current Wave Setting when Injury Occurred? (If in water)

  Select Waikiki Malibu 1 Malibu 2 Malibu 4 Turns 1 Turns 2 Turns 3 Turns 4 Turns 5 Turns 6 Barrel 1 Barrel 2 Barrel 3 Barrel 4 Barrel 5 (Beast)

  • Waikiki
  • Malibu 1
  • Malibu 2
  • Malibu 4
  • Turns 1
  • Turns 2
  • Turns 3
  • Turns 4
  • Turns 5
  • Turns 6
  • Barrel 1
  • Barrel 2
  • Barrel 3
  • Barrel 4
  • Barrel 5 (Beast)

Treatment

• Treatment Provided (please specify)

• First Aid Injury Location

  Select Head Neck Left Shoulder Right Shoulder Left Upper Arm Right Upper Arm Left Lower Arm Right Lower Arm Back Chest Left Hip Right Hip Spine Left Hand Right Hand Upper Left Leg Upper Right Leg Lower Left Leg Lower Right Leg Left Knee Right Knee Left Foot Right Foot

  • Head
  • Neck
  • Left Shoulder
  • Right Shoulder
  • Left Upper Arm
  • Right Upper Arm
  • Left Lower Arm
  • Right Lower Arm
  • Back
  • Chest
  • Left Hip
  • Right Hip
  • Spine
  • Left Hand
  • Right Hand
  • Upper Left Leg
  • Upper Right Leg
  • Lower Left Leg
  • Lower Right Leg
  • Left Knee
  • Right Knee
  • Left Foot
  • Right Foot

• Referral (Recommend Patient to Doctor or Hospital)

  No Referral

  Doctor

  Relative Contacted

  Hospital

Ambulance Disclaimer Statement

• URBNSURF​ Melbourne staff have recomended​ that Paramedics are required for further medical assistance or transport for further attention. I understand this will incur costs and I will be responsible for any costs incurred as a result of Paramedic / Ambulance assistance.

  Sign

• OR I do not request further medical assistance and will be responsible for my own medical treatment.

  Sign

Theft (Criminal Activity)

• Is this incident related to a Theft, Lost Property or Property Damage?

  No

  Yes

• You can report non-urgent crime and events anytime, anywhere by calling Victoria Police Assistance Line on 131 444 or submitting an online report. You should still call Triple Zero (000) immediately if the incident is life-threatening, needs immediate Police attendance, a crime is happening now, or an offender is (or may be) still in the area.

  

• PAL: 131 444

• Online: onlinereporting.police.vic.gov.au

WorkSafe Notifiable

• Is this Incident WorkSafe Notifiable?

  No (Not Notifiable)

  Yes (Notifiable)

• Read WorkSafe Notifiable Incident Definition below:

  

Sign Off

• Person Involved in Incident Name & Signature

  Sign

• Staff Member Name & Signature

  Sign

Further Actions

• Is Further Action Required (If 'Yes', add notes)

  No

  Yes