Health Club Incident Report Form at a glance
What it is: Health Club Incident Report Form: a loss control technical resource form from National Health Club Association, for your loss prevention and risk control efforts.
Who signs: If you investigated, you sign under Investigated By, and if you reviewed, you sign under Reviewed By.
A filled-in Health Club Incident Report Form example: a manager reports an ankle sprain
How to fill out Health Club Incident Report Form, box by box
Member Involved
Enter the Member's Name Involved in Incident, mark Sex Male or Female, and enter Age and the Member's Phone Number (Home) and (Work).
Member Address
Under Member Address, enter Street, City, State and Zip.
Report Date and Manager on Duty
Enter the Report Date (Today's Date) and the Manager on Duty at Time of Incident.
Witnesses
Enter Witness' Name #1 and Phone Number, and Witness' Name #2 and Phone Number.
Date of Incident and Time of accident
Enter the Date of Incident and the Time of accident, and mark AM or PM.
Cause of injury
Enter the Cause of injury.
Client injured by and Incident Occurred
Under Client injured by, mark Self-inflicted, Staff member or Other member.
Under Incident Occurred, mark Entering facility, Inside of facility, While exercising, Exiting facility, Outside of facility or Other.
Specific area where injury occurred
Under Specific area where injury occurred, mark Aerobic areas / studios, Spa / Jacuzzi area, Tennis / Racquetball courts, Cardiovascular areas, Steps / hallways / local areas, Track / running area, Child Care area, Swimming area / pool, Weight room area, Locker Rooms / Shower, Tanning area or Other.
Type of injury and Action Taken
Under Type of injury, mark Abrasion/scratch, Fracture/break, Sprain/strain, Contusion/bruise, Laceration/cut or Other. Under Action Taken, mark None, First Aid treatment by Staff, Other, Referred to Doctor with the Doctor's Name, Referred to nurse with the Nurse's Name, or Transported to hospital: with the Name of hospital.
Person Notified
Enter the Person Notified and the Time Notified, and mark AM or PM.
Treatment Provided and Part of body injured
Under Treatment Provided, mark None, First aid, Medical office visit, Emergency room /outpatient, Inpatient services or Other. Under Part of body injured, mark Abdomen, Eye, Leg, Arm, Foot / toes / ankle, Mouth / Teeth, Back, Hand / fingers, Neck, Chest, Head / skull, Nose, Ear, Knee or Other.
Describe Clearly How the Incident Occurred and Witnesses Account of Incident
Describe Clearly How the Incident Occurred, and write the Witnesses Account of Incident.
Analysis
Under Analysis, write what acts and / or conditions directly contributed to the incident.
Corrective Action
Under Corrective Action, write what actions have or will be taken to prevent recurrence. Enter the Corrective Action Follow-Up Date.
Investigated By and Reviewed By
Sign the Investigated By (Signature) line if you investigated, and the Reviewed By (Signature) line if you reviewed, each with its Date.
More rules for Health Club Incident Report Form
The information and suggestions in this form 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.
Sources
[1] Health Club Incident Report Form, National Health Club Association (the served file; no issuer file found) (the Official source link on this page).