FGPC & SWF Incident Report Form
To be filled in after any incident involving FGPC/ SWF coaches, staff, or athletes. Most of the questions are marked as required, so fill in "N/A" if not applicable.
Date of Incident *
MM
/
DD
/
YYYY
Time
:
Person Completing this form
Name *
Name of person completing this report
Phone Number *
Phone number of person completing this report
Email Address *
Injured or Affected Person
Name *
Name of person injured or affected in the incident
Job Title *
Birth Date
Birthday of injured or affected person
MM
/
DD
/
YYYY
Phone Number *
Phone Number of injured or affected person
Email Address *
Email address of injured or affected person
Description of Incident
Type of incident *
Required
Pre-incident *
Incident Description *
Detailed description of incident, including identification of any unsafe conditions, acts or procedures which contributed in any manner to the incident .
Weather Conditions
Wind and temperature if applicable
Police *
Were the police contacted?
Police Case Number
If police were contacted, what is the case number
Ambulance *
Was the ambulance called?
First Aid *
Was first aid administered?
Injuries and treatment *
Detailed description of injuries and treatment.
First Aid attendant *
Name and contact information for the person who administered First Aid
Witnesses *
Name and contact information of at least two witnesses to the incident.
Damage *
Detailed description of damage to property or equipment (if any)
Action taken *
Corrective Action *
Recommended corrective actions to prevent similar incidents
Follow-up
Description of follow-up if applicable
Equipment Damage Resolved
Date of resolution (if applicable)
MM
/
DD
/
YYYY
Management Action Taken
Date of action taken (if applicable)
Notes
Any additional information you find relevant
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