Hi

11:20PM, Mon 17th Jan 2022

REPORT INCIDENT

Incident details

Type of Incident

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REPORT INCIDENT

Participant/Casualty details:

Participant/Casualty DOB:

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REPORT INCIDENT

Area of injury: please select an area of the body below

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REPORT INCIDENT

Area of injury

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REPORT INCIDENT

Injury Description

Area of injury:

Current selected injury:

Descrption for the current selected injury:

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ADD ANOTHER INJURY

REPORT INCIDENT

Upload photos

You can only upload images currently stored on your device:

- Must be in .jpg, .jpeg, or .png format
- Maximum file size allowed not more than 6 MB

Uploading images of people?

Only upload photos if they are absolutely necessary. You must gain consent from any person shown in images prior to taking or uploading. You must take care to ensure that any images uploaded are appropriate for use/storage and are necessary for the purpose of injury or hazard reporting.

If you cannot confirm consent, then you must not upload images.

The upload of images is carried out entirely at your own risk and Proactive Reporting accepts no responsibility for gaining consent for the image upload, or liability for the appropriateness of images uploaded by users to the system.

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REPORT INCIDENT

Uploaded photos:

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REPORT INCIDENT

Incident description

First aid given YES NO

Any witnesses YES NO

Was additional medical assistance called for? YES NO

Parent/Guardian informed? YES NO

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REPORT INCIDENT

Incident summary

Date of incident

Time of incident

Venue

Report Completed by

Specific Location

Activity

Incident Type

Participant/Casualty Details

Participant/Casualty Name

Participant/Casualty Age, DOB

Area of injuries

Injury Description

Photos

Incident Description

Cause of incident

What happened

First aid given

First aid completed by

Witnesses

Additional Medical Assistance called for

Actions taken to prevent further incidents or risk

Any additional notes

Parent/Guardian informed

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REPORT INCIDENT

Incident completion

I have checked the information I have entered is accurate and understand that once submitted it can not be edited. YES NO

Are follow up actions required?

YES NO UNSURE

REPORT HAZARD

Hazard details

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REPORT HAZARD

Hazard details

Category of Hazard ?

Risk Rating ?

Who is at risk?
(you can select more than one)

Participants

Activity leaders

Public

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REPORT HAZARD

Hazard Action

Safe to continue
with controls in place? YES NO

Have you informed other affected members of staff? YES NO

Responsible manager/leader informed? YES NO

Venue Management informed? YES NO

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REPORT HAZARD

Upload photos

You can only upload images currently stored on your device:

- Must be in .jpg, .jpeg, or .png format
- Maximum file size allowed not more than 6 MB

Uploading images of people?

Only upload photos if they are absolutely necessary. You must gain consent from any person shown in images prior to taking or uploading. You must take care to ensure that any images uploaded are appropriate for use/storage and are necessary for the purpose of injury or hazard reporting.

If you cannot confirm consent, then you must not upload images.

The upload of images is carried out entirely at your own risk and Proactive Reporting accepts no responsibility for gaining consent for the image upload, or liability for the appropriateness of images uploaded by users to the system.

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REPORT HAZARD

Uploaded photos:

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REPORT HAZARD

Hazard Action

Any changes made to allow activities to continue? YES NO

Any long term action required? YES NO

Date to be checked again?

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REPORT HAZARD

Hazard summary

Date of assessment 17/01/2022

Time of assessment

Venue

Report Completed by

Hazard Location

Activity taking place

Hazard Details

Description

Category of Hazard

Risk Rating

Who is at risk

Photos

Safe to continue with controls in place?

Have you informed other affected members of staff?

Responsible manager/leader informed?

Venue Management informed?

Changes made to allow activities to continue

Long term action/future controls required

Date to be checked again

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REPORT HAZARD

Hazard completion

I have checked the information I have entered is accurate and understand that once submitted it can not be edited. YES NO

Are follow up actions required?

YES NO UNSURE

PRE SESSION CHECK

Any significant changes since last session? YES NO

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PRE SESSION CHECK

Has the facility been checked? YES NO

Are all facility areas safe to use? YES NO

Has the equipment been checked? YES NO

Is all equipment safe to use? YES NO

Have participants been checked (injuries/pre event checks)? YES NO

Are the participants safe to take part? YES NO

Is the environment suitable for your activity? YES NO

Is the activity safely set up with suitable drills/games prepared? YES NO

Are staff suitably qualified/experienced? YES NO

Are there enough, suitable staff to run the activity? YES NO