Pool Incident Report Form

• Incident Number

• Date and Time of Incident

  Date

• Site

  Select Beverley Boddington Darkan Narembeen Pingelly Williams Quairading

  • Beverley
  • Boddington
  • Darkan
  • Narembeen
  • Pingelly
  • Williams
  • Quairading

• Specific Location

  Select Bathrooms - Male Bathrooms - Female Bathroom - Disabled Baby Pool Learner Pool Main Pool Pool - North Side Pool - East Side Pool - West Side Pool - South Side Grandstand Pump Room Balance Tank Waste Tank North lawn East Lawn South lawn West lawn Kiosk Front area Main Paths - Inside Main Paths - Outside

  • Bathrooms - Male
  • Bathrooms - Female
  • Bathroom - Disabled
  • Baby Pool
  • Learner Pool
  • Main Pool
  • Pool - North Side
  • Pool - East Side
  • Pool - West Side
  • Pool - South Side
  • Grandstand
  • Pump Room
  • Balance Tank
  • Waste Tank
  • North lawn
  • East Lawn
  • South lawn
  • West lawn
  • Kiosk
  • Front area
  • Main Paths - Inside
  • Main Paths - Outside

• Incident or near Miss

  Incident

  Near Miss

• Has this been reported to the Shire already?

  Yes

  No

• Who was this reported to?

• What Time and Date was this reported

  Date

• Brief Description of Incident

• Photo of Incident (Multiple Photos can be attached)

  Media

Details of person(s) Involved

Person 1

• Reason for involvement (Pool Manager, Witness, Person Involved)

• Name (First & Last)

• DOB

  Date

• Gender

  Male

  Female

  Rather Not Say

• Address

• Phone Number

• Email Address

Person 2

• Reason for involvement (Pool Manager, Witness, Person Involved)

• Name (First & Last)

• DOB

  Date

• Gender

  Male

  Female

  Rather Not Say

• Address

• Phone Number

• Email Address

Person 3

• Reason for involvement (Pool Manager, Witness, Person Involved)

• Name (First & Last)

• DOB

  Date

• Gender

  Male

  Female

  Rather Not Say

• Address

• Phone Number

• Email Address

Incident Report Form

• A MAINTENANCE REQUEST FORM MUST BE COMPLETED IF THE INCIDENT MAY OCCUR AGAIN OR CAUSE INJURY OR ENVIRONMENTAL DAMAGE

• Details of Incident (give as much detail as possible) What, How, When, Where Who

• Follow Up Reccomendations

• Damage to Contract Aquatic Services Property?

  Yes

  No

• Describe the Damage and the Approximate value

• Damage to Shire Property?

  Yes

  No

• Describe the Damage and the Approximate value

• Form Completed by

• The above defect form has been completed to the best of my ability

  Sign