Club Incident Report Form PDF Details

When it comes to managing the safety and well-being of members within a health club, effectively documenting any incidents that occur is crucial. The Health Club Incident Report Form serves as a comprehensive tool, designed to capture all relevant details related to any accident or injury that happens on the premises. This form includes information about the person involved and any witnesses, specifics of the accident such as the time, cause, and nature of the injury, as well as the location within the facility where it occurred. It also outlines the type of first aid or medical attention provided, if any, and details any follow-up action taken or required to prevent future incidents. Additionally, it incorporates a section for describing the incident in detail, accounts from witnesses, an analysis of what contributed to the incident, and corrective actions to be taken. The National Health Club Association emphasizes the importance of tailoring this document to suit the specific needs of each facility, underscoring that it is not exhaustive in covering all potential hazards but is a crucial element in a club’s risk management and safety protocols. The aim is not just to comply with legal and regulatory standards but also to ensure the health and safety environment of the facility is maintained, making it a safer place for all members and staff.

QuestionAnswer
Form Name Health Club Incident Report Form
Form Length 2 pages
Fillable? Yes
Fillable fields 29
Avg. time to fill out 10 min
Other names club incident report, incident report for gyms, gym incident report form, incident report fitness facility, gym incident report

Form Preview Example

Page 1 of 2

HEALTH CLUB INCIDENT REPORT FORM

Information: (Member Involved / Witnesses)

 

Member’s Name Involved in Incident:

 

 

 

 

 

 

 

 

 

 

Sex

 

Male

 

Female

Age:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Member’s Phone Number:

(Home)

 

 

 

 

(Work)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street

 

 

City

 

 

 

 

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Member Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Report Date (Today’s Date):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Manager on Duty at Time of Incident:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Witness’ Name #1

 

 

 

 

 

 

 

 

 

 

Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Witness’ Name #2

 

 

 

 

 

 

 

 

 

 

Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accident / Injury Report

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Incident:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Time of accident:

 

 

 

AM

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cause of injury:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Client injured by:

 

 

Self-inflicted

 

 

 

 

Staff member

 

 

 

 

 

 

 

 

Other member

 

Incident Occurred:

 

 

Entering facility

 

 

 

 

Inside of facility

 

 

 

 

 

 

 

 

While exercising

 

 

 

Exiting facility

 

 

 

 

Outside of facility

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Aerobic areas / studios

 

Spa / Jacuzzi area

 

 

 

 

 

Tennis / Racquetball courts

 

Specific area where

 

 

Cardiovascular areas

 

Steps / hallways / local areas

 

 

Track / running area

 

injury occurred:

 

 

Child Care area

 

 

 

 

Swimming area / pool

 

 

 

 

 

Weight room area

 

 

 

 

Locker Rooms / Shower

 

Tanning area

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of injury:

 

 

Abrasion/scratch

 

 

 

 

Fracture/break

 

 

 

 

 

 

 

 

Sprain/strain

 

 

 

Contusion/bruise

 

 

 

 

Laceration/cut

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

None

 

 

 

 

First Aid treatment by Staff

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Referred to Doctor

 

 

 

 

Referred to nurse

 

 

 

 

 

 

 

 

Transported to hospital:

 

Action Taken:

Doctor’s Name:

 

 

 

 

Nurse’s Name:

 

 

 

 

 

 

 

Name of hospital: ___________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Person Notified:

 

 

 

 

 

 

Time Notified:

 

 

 

 

 

 

AM

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment Provided:

 

 

None

 

 

 

 

First aid

 

 

 

 

 

 

 

 

Medical office visit

 

 

 

Emergency room /outpatient

 

Inpatient services

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Abdomen

 

 

 

 

Eye

 

 

 

 

 

 

 

 

Leg

 

 

 

 

 

 

 

Arm

 

 

 

 

Foot / toes / ankle

 

 

 

 

 

 

 

 

Mouth / Teeth

 

Part of body injured:

 

 

Back

 

 

 

 

Hand / fingers

 

 

 

 

 

 

 

 

Neck

 

 

 

 

 

 

 

Chest

 

 

 

 

Head / skull

 

 

 

 

 

 

 

 

Nose

 

 

 

 

 

 

 

Ear

 

 

 

 

Knee

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The information and suggestions presented by National Health Club Association in this loss control technical resource form are for your consideration in your loss prevention and risk control efforts. They are not intended to be complete in identifying or reporting on every possible or significant hazard at your premises, preventing possible workplace accidents, or complying with all of the local, state or federal health & safety related laws or regulations. The material enclosed within this loss control reference source is intended and encouraged to be altered or redesigned by you to specifically address your hazards.

Page 2 of 2

Describe Clearly How the Incident Occurred:

Witnesses Account of Incident:

Analysis (What Acts and / or conditions directly contributed to the incident?):

Corrective Action (What actions have or will be taken to prevent recurrence):

Corrective Action Follow-Up Date:

Investigated By (Signature):

Date:

Reviewed By (Signature):

Date:

The information and suggestions presented by National Health Club Association in this loss control technical resource form are for your consideration in your loss prevention and risk control efforts. They are not intended to be complete in identifying or reporting on every possible or significant hazard at your premises, preventing possible workplace accidents, or complying with all of the local, state or federal health & safety related laws or regulations. The material enclosed within this loss control reference source is intended and encouraged to be altered or redesigned by you to specifically address your hazards.

How to Edit Health Club Incident Report Form Online for Free

Accurately completing the health club incident report form is essential for effectively documenting accidents in a club. This detailed guide helps staff members in capturing all required information.

1. Gather Personal Information

Begin by collecting the personal details of the member involved in the incident. This includes their full name, sex, age, and contact information, such as phone numbers for both home and work. If there are any witnesses, their names and contact details should also be recorded.

 

gym incident report template completion process outlined (portion 1)

2. Document the Incident Details

Record the exact date and time of the incident to help identify any patterns or conditions contributing to accidents, such as crowded facility times. Provide a detailed and clear description of what happened. This should include any events leading up to the incident and how the incident unfolded.

Filling out part 2 in gym incident report template

3. Specify the Injury

Detail the type of injury incurred and the specific body part affected. Be as precise as possible, noting the severity of the injury and any initial observations. This information will guide the necessary medical response and help assess the facility's or equipment's safety.

Analysis What Acts and  or, Witnesses Account of Incident, and Describe Clearly How the Incident in gym incident report template

4. Record Action Taken Post-Incident

Note any immediate medical treatment provided, such as first aid or external medical assistance. Include the names of staff members who assisted and any referrals to hospitals or specialists. If the injured person was sent or taken to a hospital, record the name of the hospital and any initial treatment provided there.

 

The information and suggestions, Corrective Action FollowUp Date, and The information and suggestions in gym incident report template

5. Describe Preventive Measures

After addressing the immediate needs, consider what actions can be taken to prevent a recurrence of similar incidents. Document any changes or planned changes to the environment, training, or procedures that could improve safety. This could include adjustments to equipment layout, staff training enhancements, or new safety policies.