Incident Report

The purpose of this form is to report accidents, injuries or behaviours that go against CityROCK's policies. This form should be completed less than 24 hours after the event. Any serious offences or crimes should be reported to the police. Staff are to please complete all fields below with as much information as possible.

Please select the appropriate category

Adult Minor

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First Participant's Name

First Name*

Last Name*

First Participant's Date of Birth*

First Participant's IS NOT TO SIGN, supervising staff only - THIS IS AN INTERNAL DOCUMENT

The below signature is for staff completing the incident report, not the customer involved.

First Participant's Signature*

Type Signature

Draw Signature

Click to Sign

Injured participants details

Injured participants email address *

Injured participants contact number *

Send a copy of this incident report to front desk or manager on duty

Parent or Guardian's Email Address

A signed copy of this waiver will be sent to the email address you provide.

Account of events (staff to complete)

Describe how 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?*

Yes

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 *

Joburg

Cape Town

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*

Parent or Guardian's Date of Birth*

Parent or Guardian's IS NOT TO SIGN, supervising staff only - THIS IS AN INTERNAL DOCUMENT

The below signature is for staff completing the incident report, not the customer involved.

Parent or Guardian's Signature*

Type Signature

Draw Signature

Click to Sign

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.

One or more problems exist. Please scroll up.

Agree To This Document