Fillable FITNESS INCIDENT REPORT FORM (ASHLink)

Fill Online, Printable, Fillable, Blank FITNESS INCIDENT REPORT FORM (ASHLink) Form

Use Fill to complete blank online ASHLINK pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

FITNESS INCIDENT REPORT FORM (ASHLink)

On average this form takes 16 minutes to complete

The FITNESS INCIDENT REPORT FORM (ASHLink) form is 2 pages long and contains:

  • 0 signatures
  • 9 check-boxes
  • 60 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your ASHLink forms online.

BROWSE ASHLINK FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
FITNESS INCIDENT REPORT FORM
Submission Process
Please return this Fitness Incident Report within one week of the incident to attention Julie Perez, Health Services:
• Fax to 877.515.2746
or
• Email to Juliep@ashn.com
or
• Mail to ASH Fitness Health Services Department, 10221 Wateridge Circle, San Diego, Ca 92121
• Urgent reports should be returned within 24 hours of the incident via fax or email.
• For questions, please call Julie Perez at 877.329.2746, Ext. 7453.
Fitness Center Information
*Fitness Network Location/YMCA *Instructor Name
*Fitness Network Location/YMCA/class location address
*Fitness Network Location/YMCA/instructor phone number
*Reporting party name & title.
(Please Print)
(E.G., Instructor, Club Manager, Staff Member, etc.)
*Reporting party phone number
*Reporting party signature Date
Member Information
*Member name Fitness ID
*Member address
*Member phone *Member health plan
*Gender Male Female *Age *Date of Birth
Incident Overview
*Date of Occurrence *Time of Occurrence am pm
*Date reported
Fitness Incident Report Form - 7/26/2021
Page 1 of 2
Fitness Network Location/YMCA/Instructor Name
Fitness Network Location/YMCA/Instructor Phone #:
If applicable, describe in detail any injury(ies) sustained by the member(s).
(Please provide a description of the site, type, and severity of the injury(ies].)
*Is the member a Silver&Fit member? Yes
If no, please describe other type of membership
*Is the member's emergency contact information on file?
Yes No
*Is this an urgent issue? (Examples may include chest pain, falls, injuries, dizziness, and/or fainting.) Yes No
*Did the incident occur during a Silver&Fit class within a facility or ActiveOptions class?
Yes -- Which class? Silver&Fit class name
If no, please describe any other class or activity:
*Has the member previously attended the class?
ActiveOptions class location
Yes
No
No - Member declined First Aid
No - Other
Yes. If yes, describe actions taken by EMS
(i.e., transported to hospital, released member to spouse, or
other, gave oxygen, CPR, AED, Splinted injury, wound care)
*Was EMS notified?
No - Member declined EMS
No - Other
EMS Family member Self released Other
*Member released to:
*What type of information will be required from this member in order to return to using the facility after this incident?
None
Personal statement of readiness
Verbal confirmation of health care practitioner exercise recommendations
Written health care professional specific exercise recommendations/clearance to exercise
Witness Information
*Witness 1 name & title
*Witness 2 name & title
Phone number
Phone number
Fitness Incident Report Form - 7/26/2021 Page 2 of 2
*Was First Aid administered?
Yes - I yes, name of person
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

FITNESS INCIDENT REPORT FORM (ASHLink)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 28 March 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document