ANU Sport and Recreation Association

Date & Time of Incident *

Please provide the date and time of the incident.

Location of Incident *

Please provide the location where the incident occurred.

Competition/event participating in *

Did the incident occur during (please select) *

Club Activity

ANU Sport Approved Activity

Facility Hire

Other:

Please select your Club *

(Other) please elaborate. *

Name of Affected Person *

Please provide the name of the affected person.

Phone Number of Affected Person *

Please provide the phone number of the affected person.

Email of Affected Person *

Please provide the email of the affected person.

Name of Witness *

Please provide the name of the witness.

Phone Number of Witness *

Please provide the phone number of the witness.

Email of Witness *

Please provide the email address of the witness.

Please describe the Incident *

Please provide a a clear concise description of the incident, including any previous injuries/diagnosis.

Witness Statement *

Please provide the witness statement.

Action taken following incident. *

Please describe what action was taken following the incident.

Did ANU Security or ACT Police attend the incident, if so please provide details:

If yes, please select the club.

If the incident did not occur at an Affiliated Club sanctioned activity, please leave blank.

Name & Position of Reporter *

Please provide your name and position if applicable.

Incident Report Form