Section 01

Reporter

The person filling out this form. (Not the affected person.)

Full name * Role / title * Phone Email Date filed * Time filed *

Section 02

Incident details

Date of incident * Time of incident *

Exact location at the studio *

Incident type *

Medical / passout / injury Slip, trip, or fall Property damage Verbal / behavioral incident Other

Severity *

Minor Moderate Serious Critical

Section 03

Person affected

If multiple people were affected, complete one form per person.

Full name *

Relationship to Island Movement *

Member / client Guest / day pass Employee Instructor / contractor Visitor / vendor

Phone Email Approximate age Emergency contact (name & phone)

Section 04

Witnesses

Anyone who saw what happened. Add as many as needed.

Section 05

What happened

Stick to what you saw and heard. Note approximate timing. Avoid speculation about cause — that goes in the environment and follow-up sections.

What was the person doing immediately before? * Describe the incident, in order * Observed symptoms / condition (for medical incidents) What the person said, before or after (quotes if possible)

Section 06

Environmental conditions

Important for spotting patterns — especially with repeated incidents in the same area.

Indoor temperature Ventilation / airflow Unusual fumes, odors, or chemicals Lighting Floor condition Class / activity in progress

Anything else about the environment worth noting

Section 07

Response actions

Other actions taken

Section 08

Aftermath & follow-up

Condition of person at time of filing this report Manager / owner notified (name & time) Follow-up plan External notifications (insurance, legal, etc.)

Section 09

Photos (optional)

Tap to use your camera or pick from your library. Photos are saved with this form on your device — nothing is uploaded automatically.

Incident Report