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Khandallah Tennis and Squash Club -

Incident Report Form

DETAILS OF PERSON COMPLETING THIS FORM:

First name*

Last name*

Email*

Phone*

Role/relationship with the Club*

DETAILS OF PERSON INVOLED:

Name:*

Age (if under 18)

Role/relationship to the Club*

Phone

Email address

INCIDENT DETAILS

Date of Incident*

Day

Month

Year

Time of Incident*

Location of Incident*

Type of Event*

Other:

DESCRIPTION OF WHAT HAPPENED

Describe the incident*

INJURY DETAILS (IF APPLICABLE)

Nature of injury

Body part(s) affected:

First aid provided?

Yes

No

If yes, by whom and what treatment:

Ambulance required

Yes

No

Medical treatment sought?

Yes

No

Witness Names and Contact Phone Numbers

Immediate Actions Taken:

Area secured

Activity stopped

Equipment isolated

Hazard signposted

Parent notified

Emergency services contacted

Other

HAZARDS & CONTRIBUTING FACTORS

PEOPLE

Inexperience

Lack of supervision

Fatigue

Medical condition

Behaviour / rule breach

Environment:

Wet/slippery surface

Poor lighting

Weather conditions

Trip hazards

Restricted visibility

Equipment-related:

Faulty equipment

Inappropriate equipment

Lack of equipment

Other contributing factors

Corrective actions required

Hazard removed

Hazard isolated

Procedural change

Maintenance

Training

Other

PRIVACY STATEMENT: Information is collected to ensure the health and safety of all users and will be managed per

the Privacy Act 2020.

+64 21 2125376

contact@ktsc.org.nz

https://ktsc.org.nz/

Khandallah Tennis & Squash Club

55 Delhi Crescent

Khandallah

Wellington 6035

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