Maroondah Leisure Incident Report Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Injury

• Near Miss

• Other

SECTION 1: LOCATION OF INCIDENT

• Select date

  Date

• Ringwood Golf

• Aquahub

• The Rings

• Croydon Memorial Pool

• Aquanation

• Dorset Golf

SECTION 2: DETAILS OF PERSON INVOLVED / INJURY

• NAME

• ADDRESS

• DATE OF BIRTH

  Date

• Male

• Female

• Contact number

SECTION 3: DETAILS OF GUARDIAN OR WITNESS

• NAME

• ADDRESS

• Male

• Female

• Relationship to person involved in incident

• Contact number

SECTION 4: INCIDENT DETAILS (what happened; include sequence of events leading to incident)

SECTION 5: DETAILED ACTION TAKEN AND OUTCOME

• First Aid

• Ambulance

• Police

• Other

• Staff member responding to incident

SECTION 6 : FURTHER RECOMMENDED ACTION

• Seek medical advice

• Report incident to police

• Other (specify)

SECTION 7: SIGN OFF

• Incident report completed by

• Shift supervisor

• Facility Manager

ADDITIONAL INFORMATION

• Generate maintenance request

• Hazard Inspection required