Participant Incident & Accident Report Form

Reveal QR Code

Type of Incident(Required)

Accident

Incident

Date(Required)

Time(Required)

Details of the person involved

Name(Required)

First name Last name

Address

Street Address City / Suburb State Postcode

Phone Number

Multiple people involved?

If multiple people were involved, please provide their details here.

Signature(Required)

Details of witnesses

Witness Name

First name Last name

Witness' Address

Street Address City / Suburb State Postcode

Witness' Phone Number

Multiple witnesses?

If there were multiple witnesses, please provide their details here.

Signature(Required)

Description of what happened

Accident, injury or incident details(Required)

Include location and activity undertaken at the time of incident.

Anyone Injured?(Required)

Yes

First Aid provided by staff?(Required)

Yes

Nature of injury and treatment(Required)

Name of First Aider(Required)

First name Last name

First Aider Signature(Required)

Describe any immediate action taken by coaching staff

Coaching Representative Name(Required)

First name Last name

Coaching Representative Signature(Required)

Reviewed by Coaching Manager

Coaching Manager's Comments

Was CPA raised?(Required)

Yes

CPA Number

Coaching Manager Signature(Required)

Your safety is our priority so we will make sure we will report your concerns so they are taken seriously and acted on.

You can post or email this form to us.

Our contact details are:

By Post:
Proactivity
PO Box 1044,
Bayswater VIC 3153

Phone or Email:
Phone (9am-5pm weekdays): (03) 9720 3650
Email: [email protected]

Your Privacy

We ask you for some personal information (like your name and how to contact you) so we can do something about what you are unhappy about. We also need to make sure you are safe and supported. Asking for this information is part of our child safe policy and our commitment to listening and responding to children and young people. We won’t use or disclose your personal information for any other reason than dealing with your complaint.