North Shore Athletics 

Incident Report  

Event/Activity: 

 Location: 

 Date: 

 Approximate Time of Incident:

 

Personal Injury 

Nature of Injury: 

Treatment Given: 

Name of Injured Person(s): 

Age: 

Address: 

Tel Number: 

Occupation: 

Circumstances: 

 

Property Damage 

Details of Damage: 

Name of Owner (if known): 

Address:

Tel Number:

Circumstances: 

 

Witnesses 

Name: 

Address and Contact Number: 

(repeat as needed)

 

Has the incident been reported to the police? 

Details of Officer/Station 

Was the injured person taken to hospital? 

Hospital name and location 

Please outline any implied or actual threat of legal action 

 

 

The above information is correct and complete, to the best of my knowledge. 

Name:

Address:

Contact:

Email: