Incident Report & Investigation Form - Model Aeronautical Association of Australia

Club Details

Club's Name(*)

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Address(*)

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Postcode(*)

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State

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Phone

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We require one type of contact number.

Mobile

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Email(*)

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Name of Member Involved(*)

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Membership No. AUS(*)

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Member's Address(*)

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State

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Member's Postcode(*)

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Phone

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We require one type of contact number.

Mobile

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Member's Email(*)

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Particulars of Incident

Date(*)

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Time(*)

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AM/PM

Where did the incident happen?(*)

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State

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How did the incident happen?(*)

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Is an insurance claim being made against you?(*)

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Was it reported to police?

YesNo Invalid Input

Name of Officer

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(Optional)

Police Station Notified

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(Optional)

Witnesses

Name

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Contact Number

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Address

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Post Code

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State

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Name

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Contact Number

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Address

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Damage Caused to Property

Not Applicable

- Tick if Not Applicable Invalid Input

Owner's Name

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Address

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Description of Property Damage

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Nature of Damage

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Estimated Cost $

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Injury to Persons

Not Applicable

- Tick if Not Applicable Invalid Input

Name

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Age

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Nature of Injury

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Address

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State

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Confirmation of Incident Report

All communications received from parties in this occurrence of their representatives should be immediately forwarded to the company unanswered. Do not admit liability nor reveal to the third party that you are insured.

Additional Comments

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Name of Secretary

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(*)

- I hereby declare and warrant that the foregoing particulars are true. Invalid Input

Incident Form Details

Club Name(*)

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Name of Member involved

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Contact Name(*)

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Contact Email(*)

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Contact Number(*)

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Date of incident(*)

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Time of incident(*)

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Place of Incident(*)

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Supporting Information

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File Upload

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Details of Model

Type(*)

Free Flight Control LineRadio ControlOther Invalid Input

Other

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other

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Wingspan - cm(*)

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Weight - kg(*)

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Engine Capacity/Thrust(*)

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Type of Model(*)

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e.g. Heli / Fixed Wing

Description(*)

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Power Plant(*)

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e.g. Electric / Internal Combustion (menthanol / petrol) / Gas Turbine

Construction Materials(*)

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Brand and Model Number Receiver(*)

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Brand and Model Number of Transmitter(*)

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Post Incident and Prevention

What was the result of the post incident investigation of the model/s equipment?(*)

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Recommended corrective action to prevent re-occurence(*)

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(Include who, what and when)

Name of Submitter

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Position(*)

Club Safety OfficerContest DirectorOther Invalid Input

This Form is for information purposes only. The conclusions set out in the Form are as a result of a preliminary investigation by the signatory and do not constitute in any way an admission or acceptance of any liability by or on behalf of the MAAA, its Members, or Affiliate Members.

(*)

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Incident Report/Investigation Form

Club Details

Particulars of Incident

Witnesses

Damage Caused to Property

Injury to Persons

Confirmation of Incident Report

Incident Form Details

Details of Model

Weather Conditions

Post Incident and Prevention

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