Incident Report Form

Please note that all collisions must be reported. Data from all incident reports, including near-misses, are used to look at trends and to help improve safety on the water. Individuals should fill out the form below. If you require assistance completely this form, please contact your club or email safety@rowingact.org.au

Information collected from this form may be shared with relevant parties. This includes the incident details, clubs and/or schools involved, date and time, location and any other relevant details. No personal information will be shared without consent

RA defines an incident or near incident as an event causing or involving: the loss of a person from a boat; the death of, or grievous bodily harm to, a person caused by a boat’s operations; the loss or presumed loss or abandonment of a boat; a collision with a boat; the stranding of a boat; material damage to a boat; material damage caused by a boat’s operations; danger to a person caused by a boat’s operations; danger of serious damage to a boat; and, danger of serious damage to a structure caused by a boat’s operations.

Name of Individual reporting incident *

Club or School you are from *

Role of person reporting incident *

Email *

Best contact number *

What is the email of your club safety officer or president? *

A copy of this report will be sent to this email address

What was the date of the incident? *

What other parties were involved (if known)? *

Types of boat involved *

E.g. 8+, 4-, 2x, 1x etc

Where did the incident occur? *

If possible link to a marker on an online map below

If possible, include a link to a map location

Please give a full description of the incident; this should include weather, water, and other other conditions which contributed to the incident: *

If at night or in poor visibility conditions, what lights were being shown by all parties? *

Put N/A if this does not apply

List any injuries sustained: *

Please put N/A where no injuries were sustained

List any damage sustained to boat(s) or property: *

Please put N/A where no damage was sustained

Were emergency services contacted? *

No
Police
Ambulance
Fire Brigade

Please add any further comments or additional information you think could be useful, eg list of witnesses (including contact details):

What further actions have been or will be implemented to avoid a repeat of the incident? *

Have you advised your club of this incident? *

If No please ensure that your club is informed as soon as possible. Whilst clubs will receive a copy of this report, it is also your responsibility to report this to them,

Print name *

I acknowledge that the above incident occurred and I have described this to the best of my ability.

Name

Incident Report Form

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