Medical - Injury Report

MEDICAL / INJURY REPORT - Member / Guest

To document injuries (trips, slips, falls), illness, loss of consciousness, or substantially similar events
Date incident occurred

MonthDayYear
Date
Time incident occurred

Hour Minutes

AM/PM Option
Sheriff Report if applicable
Person Reporting:

First NameLast Name
Card #
Phone #
Format: (000) 000-0000.
Injured Person:

First NameLast Name
Card #
Phone #
Format: (000) 000-0000.
Witness 1

First NameLast Name
Card #
Phone #
Format: (000) 000-0000.
Witness 2:

First NameLast Name
Card #
Phone #
Format: (000) 000-0000.
BellFairwayGrandLakeviewMarinetteMountain ViewOakmontSundial
Lakes EastLakes WestNorthRiverviewSouthQuail RunWillowbrookWillowcreek
BellLakeview
Duffeeland Dog ParkSun BowlSoftballOther
Describe exact location of incident
Slip, Trip, FallMedicalOther
Called 911Refused 911Transported by AmbulanceTransported by Other
Refused Medial TreatmentReturned to Previous ActivityAED UsedCPR / Chest Compressions Given
Describe incident in detail using FACTS ONLY no opinions or assumptions
The person completing the report:
Print Name
Email
example@example.com
RCSC Member # / Employee #
Phone
Format: (000) 000-0000.
RCSC PERSONNEL ONLY - SUPERVISOR NOTIFICATION
YesNo
Supervisor Name

First NameLast Name
Date

MonthDayYear
Date
Time

Hour Minutes

AM/PM Option
PhoneLeft Voice MailIn Persons
RCSC EMPLOYEES ONLY:
Photos EmailedProperty InspectedWork Order initiatedInsurance ContactedSafety and Compliance NotifiedNotes
Photographs of Area of Incident

No photographs of member injuries - Encourage members to take their own photos
File Upload

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Should be Empty:

MEDICAL / INJURY REPORT - Member / Guest

RCSC PERSONNEL ONLY - SUPERVISOR NOTIFICATION

RCSC EMPLOYEES ONLY:

Photographs of Area of Incident