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.
Recreation Center:

BellFairwayGrandLakeviewMarinetteMountain ViewOakmontSundial
Golf Course:

Lakes EastLakes WestNorthRiverviewSouthQuail RunWillowbrookWillowcreek
Bowling Center:

BellLakeview
Other Property:

Duffeeland Dog ParkSun BowlSoftballOther
Describe exact location of incident
Check which describes the event most accurately:

Slip, Trip, FallMedicalOther
Check all that apply:

Called 911Refused 911Transported by AmbulanceTransported by Other
Type a question

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
RCSC Supervisor Notified?

YesNo
Supervisor Name

First NameLast Name
Date

MonthDayYear
Date
Time

Hour Minutes

AM/PM Option
How Notified? ** No text notifications

PhoneLeft Voice MailIn Persons
RCSC EMPLOYEES ONLY:
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

Cancelof
File Upload

Cancelof
File Upload

Cancelof
File Upload

Cancelof
Should be Empty:

MEDICAL / INJURY REPORT - Member / Guest

RCSC PERSONNEL ONLY - SUPERVISOR NOTIFICATION

RCSC EMPLOYEES ONLY:

Photographs of Area of Incident