Injury Report Form | Falsegrip Gymnastics Training

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INJURY & INCIDENT REPORT FORM

To be completed by the Coach at the time the injury/incident occurs, or at the first available opportunity immediately after the incident occurs.

Details of the Injured Person

First Name

Last Name

Mobile

D.O.B

Gender

What level of Membership did the Injured Person hold at time of injury?

Does the Injured Person have any known/pre-existing medical conditions or injuries?

Details of Coach/Class

First Name

Last Name

Position

Mobile

Class Name

Details of Injury/Incident

Date of Injury

Time of Injury

Bodily Location of Injury

Gym location of the Incident

Did you personally witness the incident?

Describe how the injury was sustained?

Describe in detail how the incident was brought to your attention?

Were there any other people, equipment or event involved?

What treatment was provided or recommended? If no treatment was provided or recommended, please explain why?

Did the Injured Person return to and complete the class?

What advice was provided to the Injured Person and were any modifications required during the remainder of the class?

How did the Injured Person leave the location and where did they go?

Are there any additional notes to be included?

Witnesses

Was there anyone that witnessed the incident?

1. Full name

Mobile

2. Full name

Mobile

Acknowledgement and Understanding

I agree that the details provided are true and accurate to the best of my knowledge.

I understand that this form is a legal document and that I may be contacted to discuss my responses.

Signature

Sign here

Date

INJURY & INCIDENT REPORT FORM

Details of the Injured Person

Details of Coach/Class

Details of Injury/Incident

Witnesses

Acknowledgement and Understanding

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