Accident/Incident Report
Allegheny East Conference Corporation
Youth Ministries
Department
Department
Date
/
Month
/
Day
Year
Date
Name of Person Completing Form
Email Address
example@example.com
Telephone #
Format: (000) 000-0000.
Mailing Address
Name of Person Injured
Age
Sex
Male
Female
Email Address
example@example.com
Telephone #
Format: (000) 000-0000.
Mailing Address
Name of Parent/Guardian (if minor)
Email Address
example@example.com
Telephone #
Format: (000) 000-0000.
Mailing Address
Date of Accident
/
Month
/
Day
Year
Date
Time of Accident
Accident Location
Was a leader notified immediately?
Yes
No
Was injured person participating in an activity at time of injury?
Yes
No
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)
Rows
Name
Email Address
Telephone
Witness 1
Witness 2
Witness 3
Witness 4
How were parents/guardian notified?
Writing
Phone
Email
Other
Other:
Parent’s Response
Submit
Should be Empty: