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Get NHCA Health Club Incident Report Form

Page 1 of 2 HEALTH CLUB INCIDENT REPORT FORM Information Member Involved / Witnesses Member s Name Involved in Incident Member s Phone Number Home Sex Work Street City Male Female Age Zip State Member Address Report Date Today s Date Manager on Duty at Time of Incident Witness Name 1 Phone Number Accident / Injury Report Date of Incident Time of accident AM PM Cause of injury Client injured by Incident Occurred Specific area where injury occurred Type of injury Action Taken Self-inflicted Entering facility Exiting facility Aerobic areas / studios Cardiovascular areas Child Care area Locker Rooms / Shower Abrasion/scratch Contusion/bruise None Referred to Doctor Doctor s Name Person Notified Treatment Provided Part of body injured Emergency room /outpatient Abdomen Arm Back Chest Ear Staff member Other member Inside of facility While exercising Outside of facility Other Spa / Jacuzzi area Tennis / Racquetball courts Steps / hallways / local areas Track / running area Swimming area / pool Weight room area Tanning area Fracture/break Sprain/strain Laceration/cut First Aid treatment by Staff Referred to nurse Transported to hospital Nurse s Name Name of hospital Time Notified First aid Inpatient services Eye Foot / toes / ankle Hand / fingers Head / skull Knee Medical office visit Leg Mouth / Teeth Neck Nose The information and suggestions presented by National Health Club Association in this loss control technical resource form are for your consideration in your loss prevention and risk control efforts. They are not intended to be complete in identifying or reporting on every possible or significant hazard at your premises preventing possible workplace accidents or complying with all of the local state or federal health safety related laws or regulations. The material enclosed within this loss control reference source is intended and encouraged to be altered or redesigned by you to specifically address your hazards. They are not intended to be complete in identifying or reporting on every possible or significant hazard at your premises preventing possible workplace accidents or complying with all of the local state or federal health safety related laws or regulations. The material enclosed within this loss control reference source is intended and encouraged to be altered or redesigned by you to specifically address your hazards. Describe Clearly How the Incident Occurred Witnesses Account of Incident Analysis What Acts and / or conditions directly contributed to the incident Corrective Action What actions have or will be taken to prevent recurrence Investigated By Signature Date Reviewed By Signature possible or significant hazard at your premises preventing possible workplace accidents or complying with all of the local state or federal health safety related laws or regulations. They are not intended to be complete in identifying or reporting on every possible or significant hazard at your premises preventing possible workplace accidents or complying with all of the local state or federal health safety related laws or regulations. The material enclosed within this loss control reference source is intended and encouraged to be altered or redesigned by you to specifically address your hazards. .

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