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Page 1 of 2 HEALTH CLUB INCIDENT REPORT FORM Information Member Involved / Witnesses Member s Name Involved in Incident Member s Phone Number Home Sex Work Street City Male Female Age Zip State Member Address Report Date Today s Date Manager on Duty at Time of Incident Witness Name 1 Phone Number Accident / Injury Report Date of Incident Time of accident AM PM Cause of injury Client injured by Incident Occurred Specific area where injury occurred Type of injury Action Taken Self-inflicted Entering facility Exiting facility Aerobic areas / studios Cardiovascular areas Child Care area Locker Rooms / Shower Abrasion/scratch Contusion/bruise None Referred to Doctor Doctor s Name Person Notified Treatment Provided Part of body injured...
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