Incident Report Form | Shelly Park Cruising Club Inc

Particulars of incident:

Date *

Time *

Hours

Minutes

Location *

Type of incident (please circle below):

The injured person:

Name *

Age *

Phone *

Email Address *

Street Address *

City *

State/Province *

ZIP / Postal Code *

Witness(s)

Name

Phone

Describe the incident: (space overleaf for diagram if needed) *

Describe any illness or injury: What part of the body is affected and how? *

Describe any property damage: What damage was caused and how? *

Analysis: What do you think caused or contributed to the incident? *

Prevention: What action has been taken to prevent a reoccurrence? *

Treatment:

A & E Hospital: *

Doctor: *

GP Clinic/ A & M Clinic: *

Type of treatment provided: *

Notification and investigation

SPCC Committee advised by: *

Date *

Investigation conducted by: *

Date *

Risk Register updated by: *

Date *

Have all preventative actions been reviewed by the SPCC committee, and implemented? *YesNo

Health and Safety Officer Signature: *

Date completed: *

Shelly Park Cruising Club