Club Incident Report Form PDF Details

In order to ensure the safety and security of all club guests, it is important that accurate records are kept of any incidents that occur. The Club Incident Report Form can help to do just that. This form can be used to document any altercation, injury, or other occurrence at your establishment. By having this information on hand, you can better assess and address any potential risks. DOWNLOAD the free Club Incident Report Form now! ### When it comes to ensuring the safety of your guests, it's important to have accurate information on any incidents that occur. That's where the Club Incident Report Form comes in - designed specifically for clubs and bars, this form lets you document anything from altercations and injuries to other occurrences. Having this

QuestionAnswer
Form NameClub Incident Report Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesincident report for gyms, gym incident report form, incident report fitness facility, gym incident report

Form Preview Example

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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.

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gym incident report template completion process outlined (portion 1)

2. Given that the last array of fields is completed, you have to add the required details in Type of injury, Abrasionscratch Contusionbruise, None Referred to Doctor, Fracturebreak Lacerationcut, Sprainstrain Other, First Aid treatment by Staff, Other Transported to hospital, Action Taken, Doctorcids Name, Nursecids Name, Name of hospital, Person Notified, Time Notified, Treatment Provided, and None Emergency room outpatient so that you can move forward to the third step.

Filling out part 2 in gym incident report template

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

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

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