Incident Report Form

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

SECTION I

• Location of incident. (inc. studio)

• Date and time of incident

  Date

PERSON(S) INVOLOVED

• Name :

Description of Incident

• Describe Incident

• Near Miss

  Yes

  No

• Was there an injury due to the incident ?

  Yes

  No

• Detail any first-aid or medical treatment administered. (Provide names)

• Was the person taken to hospital ?

  Yes

  No

• To whom was the incident reported?

• Parent / Guardian informed (if applicable)

  Yes

  No

• Name of Parent / Guardian

• Select date

  Date

• Auditors Name

• Select date

  Date

• Signature

  Sign