Date and Time of Accident

Location (Area)

• Weightlifting Zone

• Cardio Section

• Locker Room

Reporter Name

Job Title/Role (if applicable)

• Trainer

• Staff

• Visitor

Gym Name

Phone number

Email

Name of Injured Employee

Incident Description

Provide a detailed description of the incident. Include events leading up to, during, and after the occurrence.

Type of Incident

• Slip, Trip, or Fall

• Equipment Malfunction or Misuse

• Overexertion or Strain

• Collisions or Accidental Impact

Witness Name 1

Phone number

Witness Name 2

Phone number

Upload Relevant Files

Were there any injuries?

• Yes

• No

Description of Injuries or Damages

Describe the type and severity of injuries. Specify who was injured and their condition.

Was medical attention provided?

Immediate Actions Taken

Describe actions taken to address the incident, such as first aid, equipment repair, or area inspection.

Was the incident reported to a manager or trainer?

• Yes

• No

Manager/Trainer Name

Phone Number

Additional Comments

Include any further information, suggestions, or recommendations to prevent future occurrences.