Incident Form
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Date of Incident: mm/dd/yyyy
Time Of Incident
Hour Minutes
AM
PM
AM/PM Option
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Name Of Injured Person
First Name
Last Name
Age of Injured Person
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Is The Adult With The Child The Parent or Guardian?
Yes
No
Parent or Guardian Name
First Name
Last Name
Parent Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent Email
Relationship To Child
Adult Name
First Name
Last Name
Adult Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
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Ask Injured Party To Describe What Happened In Their Own Words
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Take Photo of the Injured Person (Head to Feet)
Take A Second Photo the Injured Person
Take Photo of the Injured area on the Person
Take a Second Photo showing the Injury
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Was The Injured Person Participating In An Attraction Or Activity At The Time?
Yes
No
Did The Injury Take Place Inside Or Outside?
Inside
Outside
Other
Where Did The Injury Take Place?
Please List The Specific Location of Injury on The Property
Other Location Explanation
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Where is the injured Person saying they are injured.
Part of the body injured - Head, Face, Back, Arms, Legs, Knee, Elbow
Type Of Injury (Select All That Apply)
Cut/Scrape/Gash
Large Cut/Scrape/Gash
Bent, Twisted, Rolled
Missing Tooth
Broken Bone
Slip/Trip/Fall
Impact With Object
Impact with person
Other
Was 911 Called?
Yes
No
Refused
Was First Aid Administered?
Yes
No
Refused
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Were There Any Witness?
Yes
No
Refused
Will Witness Allow A Picture Of Their License Be Taken?
Yes
No
Take Photo Driver's License
Phone Number Of Witness
Format: (000) 000-0000.
Name Of Witness
First Name
Last Name
Email
Relationship To Injured Person
Please Select
Family
Friend
None
Were There Any Other Witness?
Yes
No
Refused
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Will Witness Allow A Picture Of Their License Be Taken?
Yes
No
Take Photo Driver's License
Name Of Second Witness
First Name
Last Name
Phone Number Of Second Witness
Format: (000) 000-0000.
Email
Relationship To Injured Person
Please Select
Family
Friend
None
Were There Any Other Witness?
Yes
No
Refused
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Will Witness Allow A Picture Of Their License Be Taken?
Yes
No
Take Photo Driver's License
Name Of Third Witness
First Name
Last Name
Phone Number Of Third Witness
Format: (000) 000-0000.
Email
Relationship To Injured Person
Please Select
Family
Friend
None
Were There Any Other Witness?
Yes
No
Refused
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Will Witness Allow A Picture Of Their License Be Taken?
Yes
No
Take Photo Driver's License
Name Of Fourth Witness
First Name
Last Name
Phone Number Of Fourth Witness
Format: (000) 000-0000.
Email
Relationship To Injured Person
Please Select
Family
Friend
None
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Additional Notes or Comments
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Press The "Next" Button To Stop The Recording.
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Name Of Person Completing The Report
First Name
Last Name
FEC Name
Signature Of Person Completing The Report
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