Incident Report

Please answer all questions. If you don’t have all the information, please interview a person who does. When completing this form, please provide FACTUAL INFORMATION ONLY.

Do not admit liability, accept responsibility or promise/offer compensation under any circumstances. Do not delay in completing this form to Speedway Australia. Failure to do so could jeopardise the entitlement to indemnity under the Public Liability Policy.

Your full name

Official position

Contact number

State

Venue

Incident date

Incident time

Which division did this happen in?

Where did the incident happen?

Describe the incident and how it occurred:

What kind of lighting illuminated the area?

How was the track moisture?

What was the surface condition like?

Who reported the incident to you?

What is their address?

Contact number

Were there any witnesses?

Yes No

Please upload any photos of the incident

Was anyone injured as a result of this incident?

Yes No

Injured person's name:

Approximate age:

Gender

What injuries were sustained?

In your opinion, the injury was:

The injured person was a:

Was it necessary to call for immediate medical assistance?

Was property damaged?

Yes No

Damaged property owner's name (if known)

Describe the damaged property:

Describe the nature of the damage:

What is the estimated cost of repair or replacement?

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