Please fill out this form and it will be sent to all Aikido Community’s instructors. Information about the IncidentType of IncidentAccidentNear miss of an accidentOffensiveDamage or stolen club propertyOther (please give details)Please give details of type of incident type *Do you want to make this report anonymously ? *NoYesIncident Reporter's First Name *Optional – Incident Reporter's Middle NameOptional – Incident Reporter's Last Name *Optional – Reporter's Street AddressStudent's Apartment, suite, etcOptional – Reporter's Student's CityOptional – Reporter's StateOptional – Reporter's Postal CodeOptional – Incident Reporter's Contact Phone NumberIncident Reporter's EmailOptional – Reporter's GenderFemaleMaleOther (please provide extra details below)Optional – Reporter's Gender Further Details0 / 200Was there minors involved in the incident (under 18) ?YesNoNo sureHas the parent/s / guardian/s been made aware of the incident ? *Yes – parent/s / guardian/s where presentYes – AfterwardNoI do not knowPlease give further details about the parent/s / guardian/s been made aware of the incident and outcomes?Location of the incident *During class on the matDuring class off the matDuring class in the change room or toiletBefore or after class on the matBefore or after class off the matBefore or after class in the change room or toiletOtherPlease provide a description of the location *What date was the incident ? *Day *Month *Year *Approximately what time was the incident ? *HoursMinutesAMPMOptional – Can you name the people involved ?0 / 100Optional – Can you name any witnesses to the incident ?0 / 100Was the people involved doing the activity that the class sensei asked them to do when the incident happened ? *YesNo (please provide details when you explain the incident in you own words)I do not knowNot relevant to the incidentPlease explain the incident in you own words *0 / 1000Was first aid given ? *YesNoI do not knowNot relevant or not needed for this incidentPlease give details of any first aid given and who gave the first aid0 / 1000Supervision and Health ReportingPlease name the Class Instructor's first name (If known and /or applicable)Please name the Class Instructor's last name (If known and /or applicable)Was the Class Sensei made aware of the incident when it happened ? *YesNoLater after classI do not knowPlease give details of why the Class Sensei was not made aware of the issue when it happenedWas the person / people involved referred onto further care / authorities ? *YesNoI do not knowOptional – Do you know the details of where the person / people involved referred onto further care / authorities ?0 / 400In your opinion did the incident get handled correctly ?YesNoI do not knowPlease give details on how you believe the incident could have be handled better0 / 400Are you aware if prescribed drugs that may impair reaction time or judgement of anyone involved ? *NoYesI do not knowThis does not mean you will be excluded from training, it does mean will endeavour to make allowances for you if at all possible.Please state which drugs: *0 / 400Are you ware if anyone involved suffered any incapacity requiring medical attention in the past 12 months ? *NoYesI do not knowThis does not mean you will be excluded from training, it does mean will endeavour to make allowances for you if at all possible.Please give details: *0 / 400Are you aware if anyone involved had any physical impairments, injuries or medical condition that currently affected them ? *NoYesI do not knowThis does not mean you will be excluded from training, it does mean will endeavour to make allowances for you if at all possible.Please describe: *0 / 400Are you aware if anyone involved had health issues including mental health that contributed to the incident ? *NoYesI do not knowThis does not mean you will be excluded from training, it does mean will endeavour to make allowances for you if at all possible.Please describe: *0 / 400Are you aware if anyone involved had at anytime ever been excluded by medical practitioner or any other person or entity or a martial arts club or organisation them from participating in martial arts or physical activity in the past ? *NoYesI do not knowThis does not mean you will be excluded from training, it does mean will endeavour to make allowances for you if at all possible.Please give details: *0 / 400Student code of conductThe Head Dojo Instructor/Instructor reserves the right to direct students to cease training and leave the mat and/or premises.Successful risk management is best achieved when all students adopt a spirit of responsibility in regard to safety issues. Students should be aware of and agree to adhere to, the following measures:Prior to Training1. Be aware of the dojo’s safety policies before undertaking training. Advice is available from Instructors.2. Notify the Head Dojo Instructor/Instructor of any pre-existing medical condition or disability prior to training. For serious conditions a medical clearance must be obtained.3. After serious injury or illness, students should not return to physical training until the student has fully recovered. If there is any doubt, a medical clearance must be obtained.4. Students must not participate if they have injuries or conditions such as serious cuts or abrasions, rashes, boils or any other contagious condition. Minor abrasions and cuts must be adequately dressed and covered prior to training.5. Remove jewellery, watches and other ornaments prior to training, which may cause injury.6. Long hair must be secured.7. Fingernails and toenails must be smooth and short.8. Wear a training gi or other appropriate clothing and ensure that it is in good repair.9. Ensure that weapons are in good repair and stored in appropriate manner when not in use.10. Cleanliness of both clothing and person is essential.11. Never train under the influence of drugs or alcohol.During Training1. At all times, obey the instructions of the Instructor including the direction to cease training.2. Students may opt to decline to participate in any activity they feel uncomfortable with.3. Students should train at a level they feel comfortable with. Always attempt a technique/activity at the basic level before proceeding to a more advanced level.4. Partners should train at the level of the least experienced partner.5. Competency at rolling and break falling is developed over a long period of time. Partners should agree prior to training whether they are prepared to take a fall (ukemi). Proceed slowly.6. Take care to avoid collisions on the mat by being aware of the other students training on the mat.7. Train only in the specific technique demonstrated by the Instructor.8. Freestyle training must be supervised by an Instructor.9. Report all accidents to the Instructor immediately. Exercise universal precautions in regard to blood-borne pathogens.10. Notify the Instructor if any medical condition becomes apparent during training that may affect safety.11. Students should pace themselves according to their level of fitness and competency.12. Students should avoid dehydration and over-exertion.In your option was the Student Code of Conduct adhere to by all people involved ? *YesNoI do not knowNo relevant to this incidentPlease give details *Optional – Any other comments you would like to share please add hereCan make any suggestions for the future to reduce the chance of a similar incident happening again or any other comment you would like to make?0 / 400On submitting this form if you provided an optional email address a confirmation email be sent to the email address you provided, if you do not receive this email, please call us. *Yes, I understand Notes – A copy of this submitted form will be emailed to all the club instructors. A copy of this submitted form will be emailed to you, unless you have submitted this form anonymously.Submit Incident Report
