Incident Report – Courthouse Employees

Name of Staff Submitting Incident Report:*

First Last

Job Title:*

Club Location:*

The Incident Applies to:*

Injury to a Member or Guest
Injury to an Employee
Unusual Event or Behavior

Injured Employee

Name*

First Last

Current Address

Street Address Address Line 2 City State ZIP Code

Phone*

Date of Birth

Injured Member or Guest

Name*

First Last

Member ID Number*

Choose One:*

Member
Guest

Current Address

Street Address Address Line 2 City State ZIP Code

Phone*

Date of Birth

Incident Information

Name

First Last

Date of Incident*

Time of Incident*

:

Location in the Club*

Describe The Incident*

The who, what, when, where, and the outcome of the incident.

Was this a bleeding incident?*

Yes
No

What body parts were involved?*

Was the person wearing appropriate clothing/equipment for the activity they were engaged in?*

Yes
No

If no, please explain.

Was Medical Attention Needed?*

Yes
No

Was 911 called?*

Yes
No

Name of emergency personnel who attended to the incident

First Last

Transported by ambulance*

Yes
No

Any witnesses to the incident*

Yes
No

Witness One

Name

First Last

Status

Address

Street Address Address Line 2 City State ZIP Code

Phone

Witness Two

Name

First Last

Status

Address

Street Address Address Line 2 City State ZIP Code

Phone

Employee Forms > Incident Report

Injured Employee

Injured Member or Guest

Incident Information

Witness One

Witness Two