HEALTH CLUB INCIDENT REPORT FORM

Information: (Member Involved / Witnesses)
Member’s Name Involved in Incident: Member’s Phone Number: (Home) Street Member Address: Report Date (Today’s Date): Manager on Duty at Time of Incident: Witness’ Name #1 Witness’ Name #2 Sex (Work) City Male Female Age: State

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Zip

Phone Number Phone Number

Accident / Injury Report
Date of Incident: Time of accident: Cause of injury: Client injured by: Incident Occurred: Specific area where injury occurred: Type of injury: Self-inflicted Entering facility Exiting facility Aerobic areas / studios Cardiovascular areas Child Care area Locker Rooms / Shower Abrasion/scratch Contusion/bruise None Referred to Doctor Doctor’s Name: Person Notified: Treatment Provided: None Emergency room /outpatient Abdomen Arm Back Chest Ear Staff member Other member Inside of facility While exercising Outside of facility Other: Spa / Jacuzzi area Tennis / Racquetball courts Steps / hallways / local areas Track / running area Swimming area / pool Weight room area Tanning area Other: Fracture/break Sprain/strain Laceration/cut Other: First Aid treatment by Staff Other: Referred to nurse Transported to hospital: Nurse’s Name: Name of hospital: ___________ Time Notified: First aid Inpatient services Eye Foot / toes / ankle Hand / fingers Head / skull Knee AM PM AM PM

Action Taken:

Part of body injured:

Medical office visit Other: Leg Mouth / Teeth Neck Nose 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.

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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.