Injury or Health Incident Report

Injury or Health Incident Report

Please provide as much information & detail as possible in the report below. If multiple parties were injured, please fill out a separate form for each party.

What information do I need?
Information you will need:
- Name of people involved
- Brief description of incident
- Were paramedics called?
- Brief description of injuries
- Witnesses to incident, including contact information
When a report regarding an injury or another incident is needed:
1. Assess the situation.
  1. Do EMTs need to be called? Does emergency contact of the injured party need to be called?
  2. If a possible head/neck/or back injury DO NOT MOVE the person. Leave exactly how you found them and call 911.
  3. If abuse, follow Abuse/Concern of harm & reporting protocol. Please check "sensitive information" box, this limits who gets the form to Executive Team and Facilities Director.
2. Take down names and information of injured party
3. Briefly explain what occurred. Focus on facts not opinions.
4. Briefly describe the action that was taken at the time.
  If need be, call a supervisor, Executive Pastor or Director of Operations.

Injured Party Information
Injured Party Information
Name*

FirstLast
Connection to CTK*
Sex*

MaleFemale
Age*
Parent/Guardian Information
Parent or Guardian Name*
Email
Phone Number*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Does the injured party have medical insurance?*

YesNo
Medical Insurance Information*