EmailMe Form - Cockburn ARC - Incident Report (MAJOR)

Incident Details

This form captures information relating to a situation which is outside the expected behviour of patrons or expected operations within the facility.

It is for incidents that include one or more of the following:

* Highly disruptive, threatening or violent behaviour
* Serious breach of entry conditions or patron code of conduct.
* Property damage, vandalism or theft
* Resulted in or have the potential to result in injury, illness or physical harm
* May result in a ban being put in place or has repercussions.
* Resulted in an ambulance being called.

If none of the above apply, please fill in a Non-Incident (Minor) report, which goes to Supervisors.

Incident Location *

Please choose the most accurate zone for the location of the incident.

Incident Location - more specifics

Provide further detail regarding where the incident occurred

Witness / Victim's Name (if relevant)

First Last

Date & time of incident *

DD / MM / YYYY HH : MM AM/PM

Best contact number

Witness / Victim Email

If issue requires follow up please get an email contact where possible

Type of Incident *

Please select the most accurate description of the incident

Please select all that occurred in this incident

Disruptive, threatening or violent behaviour

Serious breach of entry conditions or patron conduct policy

Property Damage, vandalism or theft

Had or had the potential to cause injury, illness or physical harm

Resulted in an ambulance being called

Incident Description *

Provide factual details of the incident that occurred
Use dot points wherever possible
Assess if what is written will make sense without your context or perspective
Provide relevant details only

Sign off by Witness/Victim and Staff

Signature of witness

Clear

Staff Signature *

Clear

Staff Name *

First Last

ECM

Aquatics Email

Operations Email

Health Club Email

Programs Email

Reception Email

Group fitness Email

Generic Email

Sports