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This form is used to record accidents and injuries that occur at CityROCK. It should be completed within 24 hours of the incident by staff.

Staff are asked to gather as much accurate information as possible while completing this form, and to do so with care, respect, and kindness, recognising that the customer may be injured or distressed.


Only staff to sign and complete below details
First Injured Participant Name
First Name*
Last Name*
Select Gender
First Injured Participant Date of Birth*
Date of Birth
First Staff Assisting Signature*
Injured participants details
Injured participants email address *
Injured participants contact number *
Enter email of your branch front desk or manager on duty below:
Parent or Guardian's Email Address
Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Account of events (staff to complete)
Describe how and where the incident happened with as much detail as possible *
Date and time
Date of incident *
Time of incident *
Type of injury
Part of participants body injured or any damage from incident *
Severity of incident out of 10. 1 being a graze to 10 leaving on stretcher to the hospital. *
Was an ambulance required and did they arrive?*
No
Yes
Details - injured participant
Member of CityROCK*
Yes
No
Did you have a spotter - bouldering related*
Yes
No
Top rope certified*
Yes
No
Date top rope test done
Lead certified*
Yes
No
Date Lead test done
Lead Belay device used
Have you:*
Been through a safety orientation with a CityROCK staff member?
Watched the bouldering safety video?
Watched the top rope safety video?
Has your friend/partner/coach/teacher/other signed a novice supervision waiver with you?
None of the above
Amount of experience climbing / belaying (eg. Climbing for x years/months) *
Area of climbing structures: *
Any additional things to note
Witness details
Witness Name and Surname *
Witness Contact Number *
If Lead/Top Rope - climbing partners details
Name and Surname
Contact number
Staff assisting with incident
Staff member Name and Surname: *
Manager on duty: *
Branch incident occurred *
Cape Town
Johannesburg
Pretoria
Action item
Staff to complete *
Call Cally if its more than a 5/10 - 082 453 8040
Call Robert (only if you cannot reach Cally) - 084 651 3219
Email incident report to Cally, Robert and Gym Managers or attach to cash up report
Attach waiver to incident report email
Camera footage if required

If severe and instructed by a manager or the patient agrees, important emergency contact numbers:

  • Netcare Paramedics (if they have medical aid) - 082 911
  • ER24 Paramedics (if they have medical aid) - 084 124 
  • CT Metro paramedics if no medical aid - 10177

Non- medical aid hospitals: 

  • JHB General Hospital: 011 488 4911
  • JHB Helen Joseph Hospital: 011 489 1011
  • CPT Groote Schuur: 021 404 9111
  • PTA Tshwane District Hospital: 012 354 7000

Medical aid hospitals:

  • JHB Netcare Olivedale Hospital: 011 301 0000
  • CPT Milnerton Mediclinic: 021 529 9000
  • PTA Netcare Unitas Hospital: 012 677 8000
  • PTA Life Groenkloof Hospital: 012 424 3600

Medical advice:

  • Charles Edelstein: 083 859 8310



Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Relationship*
Phone*
Select Gender
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Signature*
Electronic Signature Consent - staff to sign*
 Staff to sign: By signing this incident report, you agree that all information provided is correct and gathered to the best of your ability.


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