HuntsvilleCurlingClubInjuryReport Form
DateofIncident: TimeofIncident: Report#(OfficeUseOnly) DateofReport: NameofPersonFilingReport: Email: PhoneNumber: Signature: SECTION1–REPORTINGANINJURY
NameofInjuredPerson:
DateofBirth:
Howdidtheinjuryhappen?
Whatarethenatureofthe
injuries?
Wasfirstaid
offered/accepted?
Gender: Male
Female
Phone: Wasan
ambulance
required?
If EMS is refused, the injured Signature:
Spouse’s
person please sign.
_________________________ Signature
______________
:
Didinjuredpersonresume Reason
curling?
YesNo
____________________________
Name&PhoneWitness#1
Name&PhoneWitness#2
Someoftheinformationyouprovideinthisreportmaybepersonal.By
completingandsigningthisform,youconfirmthatyouhavegivenusauthority
PRIVACY touseandsharethisinformationwithotherinsurancecompanies,counselor
otherpeopleneededintheinvestigationorprocessingofthisreport.
SignatureofInjuredPerson (ifpossible):
InjuryorIncidentReportForm
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HuntsvilleCurlingClubPropertyDamage/Property/Violence/OtherReport Form
DateandTimeofIncident:
WheredidtheIncidentOccur?
TypeofIncident(circleone): DamagetoProperty
(pleasedescribe): DescribehowtheIncident
Occurred–provideasmuch
detailaspossible.
LossofProperty
ViolenceOther
Wasemergencyassistance required?
(ie:emergencymaintenance,
police,fireorother)
Photographs IfphotographsoftheIncidentaretaken,pleaseemailthemto
[email protected].
Additionalcommentsabout theincident(ifapplicable):
SECTION3–IMPORTANTCONTACTS
CLUBPRESIDENT
CLUBCoordinator
Health&SafetyDirector
PropertyDirector
ChiefIceMaker
EMERGENCY
JohnFurner
DarrellHarper
LouD’Alessandro
TedBionda
RoySullivan
911
705-635-1942
705-636-0499
705--774-3730
705-789-2702
705-789-8362
Instructions:
•
•
•
•
Pleasewriteorprintclearly
Provideasmuchinformationaspossible
SubmitcompletedformtotheClubCoordinator.
ThepersonfillingouttheInjuryorIncidentReportformshouldusetheirowndiscretiontodeterminewhetherornotan
immediatecalltotheClubCoordinatororPresidentisnecessary.Examplesofwhenanimmediatecallwouldbe
appropriatewouldbesituationssuchas:
o Iftheclubhasafire,majorflood,lighteningstrikeetc.
o Iftheclubhasexperiencedseriousvandalismrequiringfollowupbyinsuranceandimmediatepropertyrepair(for
instance,ifafrontwindowwasbrokenoutandclubpropertyremoved)
o Iftherewasacriticalinjuryorlossoflife.
o Iftheclubpropertyhasfailedtothepointoftheneeding‘highcost’emergencyrepairinorderfortheclubto
function(compressor,furnacecompletefailure)
InjuryorIncidentReportForm
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