GSGST Incident Report
After appropriate action is taken, please use this form to report injury, serious accident, fatality or unusual situations. The form should be completed as soon as possible after the incident.
Service Center
*
Please Select
Corpus
Harlingen
Laredo
McAllen
Victoria
Is the injured person a ...
*
Child
Adult Volunteer
GSGST Staff Member
Non Registered person
Insperity ID # or SS # (GSGST Employees ONLY)
Name of injured person
*
First Name
Last Name
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Nature of incident/accident
*
Name & Location of incident/accident
*
Date of incident/accident
*
-
Month
-
Day
Year
Date
Time of incident/accident
*
Hour Minutes
AM
PM
AM/PM Option
Was an ambulance called?
*
Yes
No
Were the police called?
*
Yes
No
Did the injured person refuse medical attention?
*
Yes
No
Troop Number
*
If not applicable type N/A
Service Unit
*
If not applicable type N/A
Describe what happened
*
Be specific: Give facts and actions taken in chronological order: avoid opinions or impressions.
Name & Phone number of witnesses
*
Name of person submitting report
*
First Name
Last Name
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Date
*
-
Month
-
Day
Year
Date
Signature
*
Attach permission slip signed by the parent/guardian and any additional documents
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