WTSDA Incident Report

This report is to be used when a incident occurs, including (but not limited to) any of the following events:

* Injury to instructor, student or spectator
* Conflict between students/Parents/Instructors/Staff
* Student / Parent is upset with actions taken by instructors or students.
* Physical damage is incurred to the building or training equipment
* A complaint is received about something that occurred at the event (beyond an administration related occurrence)

Name of Event

e.g., Region 45 Dan Camp

yesno

Date of Incident*

Date

Time Incident Occurred*

Hour Minutes

AM/PM Option

Your (the person completing this form) Name*

First NameLast Name

Your Email Address*

example@example.com

Your School*

Your Dan # (if applicable)*

Your Rank*

Your Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Location of the incident*

Please be specific as to the location, not just the event. Ex: Region 45 Tournament, ABC Event Centre, Anytown USA

YesNo

To Whom was it reported?*

Date and time it was reported to the event director*

Names of ALL Students, Parents and/or Instructors Involved (names, ages, genders and schools and instructors)*

Rows	Names	Age	Gender	School Affiliation
Students
Parents
Instructors
WTSDA Staff
Other (spectators, etc.)

Description of incident; please note if there were injuries, please provide information related to any first aid that may have been administered (and by whom it was administered) (OBSERVABLE FACTS ONLY; please be detailed)*

Actions taken by the WTSDA*

yesnonot applicable

Date of contact*

Date

In PersonPhoneEmailOther

Is there anything else that you would like to share? Please refrain from expressing opinions about the incident itself.*

Please add any supporting documentation (e.g., pictures, reports of EMTs, copies of ID, etc.), IF ANY

I certify that the information contained in this Incident Report is true and collect to the best of my recollection.*