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MEMBER LOGIN
Incident Report
Incident Report
SECTION 1 – YOUR INFORMATION
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The information of the person filling out the form. Whether or not you were directly involved in the incident itself.
Submitted by
*
Submitted by
First Name
First Name
Last Name
Last Name
Phone
Email
SECTION 2 – INCIDENT INFORMATION
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Incident Type
*
Injury
Near Miss
Collision
Man overboard
Inappropiate Conduct
Security
Environment
Other
Other
Location of Incident
*
Main Clubhouse
Harstand Works Area
Marina
Dinghy Clubhouse
Carpark
On water
Other
Other
Typoe of Loss/Damage
*
Personal Injury
Personal Property
FSC Property
Other
Other
Date of Incident
*
Specific Area of Location (if Applicable)
Incident Description
SECTION 3 – INVOLVED PERSON 1
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Name
*
Name
First
First
Last
Last
Phone
Who is Person 1?
*
Injured Person
Complainant
Witness
Other
Other
Relationship to site
*
Employee
Contractor
Member
Visitor
Public
Address
Address
Address
Address
City
City
State
State
Postal
Postal
SECTION 4 – INVOLVED PERSON 2
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Name
Name
First
First
Last
Last
Phone
Who is Person 2?
Injured Person
Complainant
Witness
Other
Other
Relationship to site
Employee
Contractor
Member
Visitor
Public
Address
Address
Address
Address
City
City
State
State
Postal
Postal
SECTION 5 – INJURY AND/OR ACCIDENT INFORMATION
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Nature of Injury
What tasks were occuring when the injury happened:
Was the incident reported to a supervisor or duty officer of the day?
Yes
No
Name of supervisor or duty officer
Name of supervisor or duty officer
First
First
Last
Last
SECTION 6 – EMERGENCY RESPONSE
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Signs and symptoms of injury
Treatment Required
N/A
First Aid
Referred to Doctor/Hospital
Taken by Ambulance
Refused Treatment
Other
Other
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