Atlanta Fringe Festival Emergency Incident Form
Use this form to report any incident that involves a physical injury, and/or involves police, fire, or public health officials.
Name of Report Preparer
*
First Name
Last Name
Phone Number of Report Preparer
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email of Report Preparer
*
example@example.com
Position of Report Preparer
*
Were emergency services (911) contacted?
*
Yes
No
Were non-emergency public authorities contacted?
Yes
No
Name(s) and Badge Number(s) of emergency and/or non-emergency responders?
Date of Incident
*
-
Month
-
Day
Year
Date
Time of Incident
Location of Incident
*
Incident Details (What happened? Who was involved? Was is resolved?)
*
Name of Injured Person (if applicable)
First Name
Last Name
Phone Number of Injured Person (if applicable)
Please enter a valid phone number.
Format: (000) 000-0000.
Email of Injured Person (if applicable)
example@example.com
Address of Injured Person (if applicable)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth of Injured Person (if applicable)
-
Month
-
Day
Year
Date
Who was the injured person (if applicable)
Audience
Artist
Volunteer
Staff
Other
Type of Injury (if applicable)
Does this injury require a physician/hospital visit? (if applicable)
Yes
No
Physician and/or Hospital Name, Phone Number, Address. (if applicable)
Signature. I attest this report is true to the best of my knowledge.
*
Signature Date.
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: