Accident/Incident Report

Accident/Incident Report
Allegheny East Conference Corporation Youth Ministries Department
Department
Date

MonthDayYear
Date
Name of Person Completing Form
Email Address
example@example.com
Telephone #
Mailing Address
Name of Person Injured
Age
Sex

MaleFemale
Email Address
example@example.com
Telephone #
Mailing Address
Name of Parent/Guardian (if minor)
Email Address
example@example.com
Telephone #
Mailing Address
Date of Accident

MonthDayYear
Date
Time of Accident
Accident Location
Was a leader notified immediately?

YesNo
Was injured person participating in an activity at time of injury?

YesNo
What Activity?
Describe the sequence of incident/activity in detail including what the injured person was doing at the time.
Any equipment involved in accident? If YES, what kind? if NO, put N/A.
Emergency procedure followed at time of incident/accident?
By whom was procedure followed by?

Witnesses Information (Signed statements can be attached)