For printing and copying this template Require Acrobat Reader

Appendix B

Appendix B: Sample Gymnasium Facilities Safety Report
SITE NAME:
Inspection date: ____________________ Time: ______________________________ Inspected by: ___________________________________________
INSPECT FOR:			MEETS SAFE STANDARDS		COMMENT/FOLLOW UP ACTION
			YES	NO
GYMNASIUM SPACE free of "stored" furniture/boxes/equipment along perimeter walls and corners
FLOORS clean and dry
provide for safe foot traction
clear of objects which may cause tripping/slipping
floor sockets covered and flush with floor
floor plates secure in floor, hooks and plates in good condition and flush with floor
ENTRANCES/EXITS free of obstructions
no door knobs, protruding handles on gym side of door
doors open away from gym area
exit lights/signs working
area near doors well lit
STAIRS clear of obstacles
stair treads in good condition
railings secure
treads and railings free of protruding nails, cracks or splinters
CEILING tiles and meshings on lights secure
WALLS all outlets, switches, registers, etc. flush with wall surface
free of protruding hooks, nails, etc.

Appendix B: Sample Gymnasium Facilities Safety Report (continued)
INSPECT FOR:			MEETS SAFE STANDARDS		COMMENT/FOLLOW UP ACTION
			YES	NO
BASKETBALL BACKSTOP backboards in good condition
cable and attachments from backboard to wall secure
rims secure and straight
velcro strips on walls behind backboards in good condition to hold mats
winch not located directly below a wall mounted backboard
CHINNING BARS securely attached to wall
adjustable parts in good condition
PEG BOARDS securely attached to wall
peg holes and pegs in good condition
STORAGE ROOM floor clean
centre area clear of equipment
equipment stored on designated shelves
volleyball poles secured to wall when stored standing up (to prevent falling)
EMERGENCY EQUIPMENT • first aid kit fully stocked and accessible
emergency numbers posted
access to phone/office via P.A. system
IMMOVABLE OBSTRUCTIONS • stages, water fountains, etc. padded and/or removed from play area
• a "stop" line established with pylons
BENCHES top and supports free from cracks and splinters
bolts and screws secure
OTHER

For printing and copying this template Require Acrobat Reader

Appendix C

Appendix C: Sample Outside Facilities Safety Report
SITE NAME:
Inspection date: ____________________ Time: ______________________________ Inspected by: ___________________________________________
INSPECT FOR:			MEETS SAFE STANDARDS		COMMENT/FOLLOW UP ACTION
			YES	NO
WALKING AND PLAYING SURFACES asphalt areas - level and free of holes/broken asphalt
grass and dirt areas - free of holes/ruts
clear of broken glass, cans, rocks, animal feces, etc.
free of drainage problems
clear of hazards that might cause tripping (exposed footings, roots or other environmental obstacles)
STAIRS clear of obstacles
stair treads in good condition
railings secure
treads and railings free of protruding nails, cracks or splinters
BEES’ NESTS free of nests
METAL FENCING clips and attachments safely secure
fencing tight and secure to frame
no holes in fence or between ground and fence
anchors to ground stable, in good condition and safely covered
posts corrosion free
BENCHES/BLEACHERS free of protruding nails, splinters, cracked or rotted wood
anchors to ground in good condition and safely covered

Appendix C: Sample Outside Facilities Safety Report (continued)
INSPECT FOR:			MEETS SAFE STANDARDS		COMMENT/FOLLOW UP ACTION
			YES	NO
SOFTBALL BACKSTOP fencing clips and attachments safely secure
fencing tight and secure to frame
no holes in fence or between ground and fence
anchors to ground stable, in good condition and safely covered
posts corrosion free
SOFTBALL PLAYING SURFACE level ground with good drainage
free of holes/ruts/trash/animal feces
SOCCER GOALS framework free from protruding hooks
anchors to ground stable, in good condition and safely covered
posts corrosion free
SOCCER PLAYING SURFACE level ground with good drainage
free of holes/ruts/trash/animal feces
BASKETBALL BACKSTOPS • backboards in good condition
rims secure and straight
pole anchors stable, in good condition and safely covered
poles corrosion free
BASKETBALL PLAYING SURFACE level playing surface
free of holes/ruts/trash/animal feces
POTENTIAL HAZARDS ON SCHOOL YARD no trees, exposed roots, posts, streams and other environmental hazards
hazards identified to all staff and students
warning signs and barriers erected where needed
rules for safe play around hazards are communicated to all students
OTHER

For printing and copying this template Require Acrobat Reader

Appendix D

Appendix D: Sample Activity Room Safety Guidelines An activity room is a non-gymnasium that is used for physical activities. Examples of activity rooms include church or community halls, empty classrooms, multipurpose rooms, and school basements.

When using an activity room for physical education instruction, implement the following recommendations: 1) An activity room is best suited for activities which have a controlled amount of activity (e.g., aerobics, mat work, fitness stations, skipping, wrestling, dance, bean bag activities, and chair activities). Avoid ball throwing for distance, dodgeball-type games, and games which are "action packed" and require students to run from one end of the room to another (e.g., tag, soccer, floor hockey). 2) Implement a "no body contact" rule. 3) There should be only one physical education class in the activity room at any one time. 4) If the activity room is an open area, student traffic should go around, not through the class. 5) Structure drills to provide as much organization as possible.

6) Caution students not to throw objects against the ceiling, thereby knocking down tiles, dust and lights. 7) Try to keep activity away from drinking fountains, stage steps, and trophy cases. Centre all activities to allow for a "safety zone" at least one metre around the perimeter of the room. Mark out the activity area with cones or pylons. 8) Take precautions to ensure that doors are not opened into the activity area. 9) Do not allow students to participate in activities while the teacher goes to the gym or to a storage area to get equipment. 10) Check to ensure that the floor surface is not slippery from water or dirt and that equipment/furniture is not in the way of activity.

For printing and copying this template Require Acrobat Reader

Appendix E

Appendix E: Sample Gymnasium Equipment Safety Report
SITE NAME:
Inspection date: ____________________ Time: ______________________________ Inspected by: ___________________________________________
INSPECT FOR:			MEETS SAFE STANDARDS		COMMENT/FOLLOW UP ACTION
			YES	NO
VOLLEYBALL POSTS hooks, pulleys and ratchet in good condition
• poles secured to wall when stored standing up (to prevent falling)
VOLLEYBALL NET free of exposed wires along top and frayed wires along poles
free of tears/holes
BADMINTON rackets useable, no splinters
HIGH JUMP standards, base attachments and uprights in good condition
portable pit cover free of tears
portable pit foam in good condition
crossbars taped and free of cracks/splinters
MATS tiles and meshings on lights secure
foam in good condition
velcro fasteners continue to stick
SCOOTER BOARDS wheels secure
free of cracks, broken edges

Appendix E: Sample Gymnasium Equipment Safety Report (continued)
INSPECT FOR:			MEETS SAFE STANDARDS		COMMENT/FOLLOW UP ACTION
			YES	NO
BALL CARRIERS casters working well
no sharp edges
SOFTBALL wooden bats uncracked with a good grip
GYMNASTICS - VAULTING BOX (BOX HORSE) pad and cover free from tears and wearing
sufficient padding to absorb impact
inner post solid
free of cracks/splinters
nuts/bolts/screws tight
BEAT BOARD free of splinters
springs in good condition
floor protection pads in good condition
HOOPS • no cracks/bends
BALL HOCKEY/FLOOR HOCKEY goals - welds and frames in good condition
wooden floor hockey sticks free of splinters
plastic ball hockey sticks free of cracks or broken edges/ends
blades of sticks secure to shaft
OTHER

For printing and copying this template Require Acrobat Reader

Appendix F

Appendix F: First Aid Kit
A first aid kit should be located in each area of the school where there is potential for injury. For example, it would be appropriate to have a first aid kit in the gym, the industrial arts lab and the science lab. When students are participating in activities away from the school, a first aid kit should be placed in an easily accessible location. For sports such as cross-country running or skiing, which take students away from a central location, it may be appropriate for the teacher/instructor to carry basic first aid items in a waist pack. There is no single recommended list for the contents of a first aid kit. It depends entirely on the type of activity (and thus the type of injuries that might occur) and the skill and knowledge of the people who will be using the kit. For example, there is little point in including tape in a first aid kit if no one in the school knows how to tape sprains and pulled muscles. The Sports Medicine Council of Saskatchewan sells four different first aid kits (small to deluxe) ranging in price from about $30 to about $250. It is easier and less expensive to purchase these prepared kits than to try to assemble a kit by purchasing individual components from a drugstore. These kits can be purchased from: Sports Medicine Council of Saskatchewan 1860 Lorne Street Regina, SK S4P 2L7 Phone: (306) 780-9208 or 780-9446 Fax: (306) 780-9416 In addition to selling prepackaged kits, the Sports Medicine Council also provides lists for the recommended contents of taping kits and sideline waist packs.				In general, every gym should be equipped with the following: basic first aid items (appropriate to the activity and the first aid skill of the instructor) blankets emergency phone numbers - taped inside the first aid kit and on the wall by the phone readily accessible supply of latex gloves outline of accident response plan - taped on wall accident/injury report forms Every first aid kit must be kept fully stocked. One person should be assigned responsibility for checking the contents of the physical education first aid kits regularly (every week) and replenishing the supplies that are used up.

For printing and copying this template Require Acrobat Reader

Appendix G

Appendix G: Sample Medical Information Form

MEDICAL INFORMATION FOR PARTICIPATION IN PHYSICAL EDUCATION (School Name) Dear Parent/Guardian: Vigorous physical activity is essential for normal, healthy growth and development. Growing bones and muscles require not only good nutrition, but also the stimulation of vigorous physical activity. Active participation in games, fitness activities, dance, gymnastics and outdoor activities provides opportunities for students to gain the confidence necessary to pursue a physically active lifestyle. Physical education programs allow students to experience the fitness feeling and to help them understand and make decisions regarding personal fitness and the value of physical activity in their daily lives. Occasionally activities such as cross-country-running and skating will take students off the school grounds and into the immediate community. These are important components of the physical education program and direct supervision will be provided. When activities such as downhill skiing involve bus trips, a parent consent form will be sent home with students.

The potential for injury exists in every athletic activity and is greater in some activities than in others. Injuries may range from minor sprains and strains to more serious injuries. The safety and well-being of students is a prime concern and attempts are made to manage, as effectively as possible, the foreseeable risks inherent in physical activity. It is important that your child participate safely and comfortably in the physical education program. In your child’s best interests we recommend the following: an annual medical examination. appropriate clothing for safe participation (T-shirt, shorts or track pants and running shoes). Students must not wear jewelry or chew gum during physical activity. a headband and/or glasses with shatterproof glass if your child wears glasses which cannot be removed during physical education classes. sun protection for all outdoor activities. Sun protection includes sunscreen, sunglasses, a hat and appropriate protective clothing. safety inspection at home of any equipment brought to school for class use (e.g., skis, skates, helmets).

Appendix G: Sample Medical Information Form (continued)

Please complete the form attached and have your child return it to his/her teacher.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

MEDICAL INFORMATION FORM

Name of Student: ________________________________________________ Course: ________________________________________________________ Teacher: _______________________________________________________ 1. Please indicate if your child has been subject to any of the following and provide pertinent details: epilepsy, diabetes, orthopaedic problems, heart disorders, asthma, allergies: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ head or back conditions or injuries (in the past two years): _____________________________________________________________ _____________________________________________________________ arthritis or rheumatism; chronic nosebleeds; dizziness; fainting; headaches; dislocated shoulder; hernia; swollen, hyper-mobile or painful joints; trick or lock knee: ____________________________________________________________

2. What medication(s) should your child have on hand during sports activities? ____________________________________________________________ Please note that medicine is dispensed in accordance with board of education policy. Contact the school principal for more information. 3. Does your child wear a medic alert bracelet, neck chain or carry a medic alert card? Yes _____ No _____ If yes, please specify what is written on it: ____________________________________________________________ 1. Please describe any other relevant medical conditions that will limit your child’s full participation in sports activities. ____________________________________________________________ ____________________________________________________________ 2. Student Signature: ____________________________ Date: __________ Parent/Guardian Signature: _____________________ Date: __________

For printing and copying this template Require Acrobat Reader

Appendix H

Appendix H: Sample Accident Response Plan

There is the potential for injury in all physical activities. Therefore, it is important to have an emergency action plan. The key to any emergency action plan is getting professional care to the student as quickly as possible. Know the following information: 1) Location and means of access to a first aid kit. 2) Location of a telephone. 3) Telephone number of ambulance and hospital. 4) Directions and best access routes to hospital. 5) Location of vehicles on the school site which could be used to transport students to hospital. When an injury occurs: 1) Take control and assess the situation. 13) Remember the basic first aid rule: Do not move the injured student. If student cannot start a movement by himself/herself, do not move the body part for him/her. 3) Tell bystanders to leave the injured student alone. 4) Leave the student’s equipment in place. 5) Evaluate the injury. Once you have assessed the severity of the injury, decide whether further assistance is required. 6) If an ambulance is not needed, decide how to remove the injured student from the playing surface. 7) If an ambulance is required: a) Request assistance from another person (teacher/administrator/parent)

b) Have the second person call an ambulance and give the following information: state that it is a medical emergency state what the emergency is give the exact location and the name of the closest cross streets c) give the telephone number from which you are calling. d) After the other person has called the ambulance, he/she should report back to the person in charge, confirm the call and give the estimated time that the ambulance will arrive e) Have someone go to the entrance and wait for the ambulance. 8) Once the ambulance has been called, observe the injured person carefully for any change in condition, and try to reassure the injured student until professional help arrives. 9) Do not move the injured person unnecessarily. 10) Do not give the injured person food or drink. 11) Stay calm. Keep an even tone in your voice. 12) When ambulance attendants arrive, tell them what happened, how it happened and what you have done. If possible, inform the ambulance attendants about any medical problems or past injuries that the injured person may have experienced. 13) Accompany the injured person to the hospital to help reassure him or her and to give the relevant medical history and injury circumstances to the physician. 14) If the injured person is a student, contact the parents/guardians as soon as possible after injury. 15) Complete an accident report and file it with appropriate school board official and school administrator. For after school and outdoor activities, have access to a cellular phone.

For printing and copying this template Require Acrobat Reader

Appendix I

Appendix I: Sample Accident/Injury Report Form

Marsh & McLennan

MARSH & McLENNAN (SASK.) LTD. SUITE 205 B 2222 B 13TH AVENUE Phone No. (306) 525-5120 REGINA, SK S4P 3M7 FAX No. (306) 352-9633	SASKATCHEWAN SCHOOL TRUSTEES ASSOCIATION 400 B 2222 B 13th AVENUE Phone No. (306) 569-0750 REGINA, SK S4P 3M7 FAX No. (306) 352-9633
SCHOOL/COLLEGE/INSTITUTE INCIDENT REPORT FORM FOR INSURANCE PURPOSES
1. GENERAL
Name/Number of School or Name and Location of College/Institute Facility: _______________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ Name of School Division: _______________________________________________________________________________________________________________________________________ Date of Incident (M/D/Y) ________________________________ Time __________ : __________ a.m./p.m. Telephone # _____________________________________________ Description of how incident occurred:: _________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________
WITNESSES: (1) Name: _____________________________________________________________ Teacher/Instructor/Other: ______________________________________________ Witness Activity at time: _______________________________________________ (2) Name: ____________________________________________________________ Teacher/Instructor/Other: _______________________________________________ Witness Activity at time: _______________________________________________	Location of Incident: L01 ( ) Basement L02 ( ) Cafeteria/Lunchroom L03 ( ) Classroom L04 ( ) Shops/Lab/Kitchen L05 ( ) Doors/Entrance Areas L06 ( ) Dormitories L07 ( ) Gymnasium/Auditorium L08 ( ) Hallways/Lockers L09 ( ) Library/Office/Lounge/Study Room L10 ( ) Park/Grounds L11 ( ) Parking Lot	L12 ( ) Playing Fields L13 ( ) Playground Equipment L14 ( ) Pool L15 ( ) Rink L16 ( ) Sidewalks/Roads off Facility Property L17 ( ) Stairs within Building L18 ( ) Stairs/Sidewalks within Grounds L19 ( ) Washrooms/Changing Rooms/Showers L20 ( ) Other B (Please Explain) ________________________________

2. COMPLETE THE APPROPRIATE SECTION For Bodily Injury/Other Party Damage complete Section "A" For Loss or Damage to Facility and/or Contents complete Section "B"
SECTION A
Name of Person Involved ___________________________________________________________________________________________________________ Age: _______ M/F: ______ Address: __________________________________________________________ Postal Code: ________________ Grade/Year/Night School: _________________________________ (Schools Only) Student/Visitor/Other: (Explain) _____________________________________________________________________________________________________________________________ Division/Program: _________________________________________________________________________________________________________________________________________ Parent/Guardian/Emergency Contact: _________________________________________________________________________________________________ Notified? (Y/N) _____ How? ___________________________________________________________________________________________________________________________________________________ Telephone # _______________________________________ Parent/Guardian/Emergency Contact Instructions: ________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ Emergency Treatment: (Y/N) ________ What? __________________________________________________ By Whom? ___________________________________________________ Advised to seek medical treatment: (Y/N) _______ Hospitalized? (Y/N) _______ Where? __________________________________________________________________________ How transported? __________________________________________________________________________________________________________________________________________
Nature of Injury/Damage: N01 ( ) Bruise/Abrasion/Swelling N02 ( ) Burn N03 ( ) Concussion (Suspected) N04 ( ) Crushed N05 ( ) Dental Damage N06 ( ) Dislocation N07 ( ) Fatality/Death N08 ( ) Fracture N09 ( ) Imbedded Object	N10 ( ) No Information N11 ( ) Nosebleed N12 ( ) Open Wound/Laceration N13 ( ) Sprain/Strain (Suspected) N14 ( ) Winded N15 ( ) Property Damage/Other Party N16 ( ) Bites/Stings N17 ( ) Other B (Please Explain) _________________________________	Body Area: B01 ( ) Arms/Shoulder/Elbow B02 ( ) Chest/Abdomen/Pelvis B03 ( ) Eyes B04 ( ) Face B05 ( ) Feet/Toes B06 ( ) Fingers/Hands/Wrists B07 ( ) Head/Forehead	B08 ( ) Legs/Knees/Ankles B09 ( ) Multiple Areas B10 ( ) Neck B11 ( ) No Information B12 ( ) Spine/Back B13 ( ) Teeth/Mouth B14 ( ) Other B (Please Explain) ________________________________
Cause of Injury or Damage: C01 ( ) Assault B No Weapon C02 ( ) Assault with Weapon C03 ( ) Choking/Suffocation C04 ( ) Drowning C05 ( ) Exposure to Flame/ Electricity or Hot Caustic Substance C06 ( ) Fall at Same Height C07 ( ) Fall from Different Height C08 ( ) Fatigue/Over Exertion C09 ( ) Foreign Body	C10 ( ) Horseplay C11 ( ) Maintenance Activity C12 ( ) Motor Vehicle Accident C13 ( ) Poison/Allergic Reaction C14 ( ) School Bus Accident C15 ( ) Sports Injury C16 ( ) Struck Against Person C17 ( ) Struck/Crushed By/Against Object C18 ( ) Other - (Please Explain) _________________________________	Activity at Time of Incident: A01 ( ) Academic Classroom A02 ( ) Between Classes A03 ( ) Extra-Curricular (i.e. Club) A04 ( ) Out-of-Class Field Trip A05 ( ) Recess/Pre- or Post-Class/Noon Hour	A06 ( ) Sports Event A07 ( ) Sports-Related Class A08 ( ) Travel to or from Facility A09 ( ) Unorganized Sports A10 ( ) Work Placement A11 ( ) Maintenance Activity A12 ( ) Other B (Please Explain) ________________________________

SECTION B
Property Involved (Describe property involved and extent of loss and/or damage): ___________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Fire Department Attended: (Y/N) _______ Report Number: _______________________ Were Police Notified? (Y/N) __________ Branch/Detachment: _________________________________ Case Number: ___________ Date (M/D/Y) ________________________ Time _______ : _______ a.m./p.m. Were there visible sings of forced entry? (Y/N) ______________ What? (Explain) _____________________________________________________________ ___________________________________________________________________________	Cause of Loss/Damage: C01 ( ) Burglary/Forcible Entry C02 ( ) Collapse C03 ( ) Dishonesty/Infidelity C04 ( ) Explosion C05 ( ) Falling Object C06 ( ) Fire/Lightning C07 ( ) Glass Breakage C08 ( ) Impact by Vehicle/Aircraft C09 ( ) Riot	C10 ( ) Robbery C11 ( ) Smoke C12 ( ) Theft C13 ( ) Transportation C14 ( ) Vandalism/Malicious Acts C15 ( ) Water Escape/Rupture/ Freezing C16 ( ) Windstorm/Hail C17 ( ) Other B (Please Explain) ________________________________
3. SIGNATURES AND DATE
Name of Person Completing Report: ______________________________________________________ _________________________________________________________________ (Please Print or Type) ( Signature) Name of Administrator: ________________________________________________________________ _________________________________________________________________ (Please Print or Type) (Signature) Date: ________________________________________________

Incident Report Form used with permission of Marsh & McLellan (Sask.) Ltd.