Incident Report Form
Date of Incident
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Incident
Hour Minutes
AM
PM
AM/PM Option
Where did Incident Occur:
Incident Reported by:
First Name
Last Name
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Name of Person(s) Involved:
Role (e.g. athlete, coach, spectator):
Additional Party.. (if applicable):
Role of additional party (if applicable):
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Type of Incident (e.g., injury, property damage, rule violation):
Detailed Description of the incident (Include events leading up to the incident, actions taken, and any contributing factors):
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Witness Name + Contact Info (List additional witness, if applicable)
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Immediate Actions Taken (e.g., first aid, facility lockdown, equipment removal):
Was Emergency Medical Services (EMS) Contacted? (If yes, include EMS Arrival time):
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Name of Person Completing form:
First Name
Last Name
Signature
Submit
Should be Empty: