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07 5524 3655
4 Minjungbal Dr, Tweed Heads South
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First Aid Incident
Code Blue
Please fill out the form below for any first aid emergencies
"
*
" indicates required fields
Date
*
DD slash MM slash YYYY
Time
Hours
:
Minutes
Patient First Name (if available)
Patient Last Name (if available)
Customer detail
Member
Visitor
Contractor
Staff
Other
Unknown
Member number (if member)
Address (if available)
Street Address
Address Line 2
City
State / Province / Region
Phone number (if possible)
Location of Injury on Patient
Head
Neck
Face
Chest
Abdomen
Pelvis
Leg
Foot
Arm
Hand
Other
Type of injury
Break
Abrasion
Puncture
Penetration
Intoxication
Burn
Sprain/Strain
Cut
Heat Stress
Bruising
Stroke
Fainting
Fall
Other
Any medical history?
Nature of Injury:
What treatment was provided?
Basic First Aid
Advanced First Aid (Fracture/Tourniquet)
Oxygen
CPR
AED
Other
Was an Ambulance called?
Yes
No
Treatment summary
Photos (Select files and take photo or add a photo from gallery of phone)
Drop files here or
Select files
Max. file size: 2 MB.
Add photos of the area the incident happened and injuries sustained if permission is given by patient
Area incident took place:
Carpark
Garden surrounds
Bowls Greens
Reception Foyer
Cafe
Skylines
Restaurant
Secret Garden
Function Rooms
Gaming Room
Auditorium
Members Area
Toilets
Bus
Other
Anything else you wish to add:
Staff Member First Name
Staff Member Last Name
Date Form Lodged
DD slash MM slash YYYY
Time Form Lodged
Hours
:
Minutes
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Home Page
Bar & Dining
Restaurant
The Cafe
What’s On
Entertainment
Events
What’s On
Sports
Bowls
Sports
Game On
Functions
Membership
Membership Sign Up
Membership Renewal
Our Club
Contact
Sub Clubs/Partners
ClubGRANTS
Careers
Courtesy Bus
Courtesy Bus
07 5524 3655
4 Minjungbal Dr, Tweed Heads South
