Incident Report Form Reporting Swimming Club * Event Category * Harm Damage Potential Harm Potential Damage Other Event Date * MM DD YYYY Was assistance required from facility staff? * Yes No Was the facility manager notified? * Yes No Did you need to notify WorkSafe New Zealand of the incident or injury? * E.g. injury requiring an ambulance or hospital services Yes No WorkSafe NZ Notification WorkSafe NZ Notified by if applicable Date of WorkSafe NZ Notification: if applicable MM DD YYYY Incident Details Type of Injury or Illness * Abrasion Allergy Asthma Burn Cardiac Concussion Fatigue Fracture Gastro-intestinal Hyperthermia Hypothermia Sprain Strain Other Team Manager in Charge / Attending the Incident * Details of Person Involved Name * Age * Gender * Female Male Other Contact E-mail * Contact Number * Country (###) ### #### Witness Details Name if applicable Contact E-mail if applicable Contact Number if applicable Country (###) ### #### Witness Event Description if applicable: short description of what happened leading up to, and after the incident. Include details on condition of person involved. Event Description Injury / Illness Sustained * e.g. bump on the head The Action that Occurred * e.g. kicked by another swimmer Likely or Possible Cause * e.g. congested warm-up session Possible Causes * e.g. fooling around Next Steps Recommended Actions * Person Responsible * Completion Date * MM DD YYYY Agreement & Submission The details provided in this report are true and accurate to the best of knowledge. This report has been passed by the relevant parties before completion. * I agree to the terms and conditions stated above Your inidn
