SRSRC Accident/Incident Report

Accident/Incident Report
Name of employee completing report*

First NameLast Name
Date and time of accident/incident*

MonthDayYear
Date
Hour MinutesAM/PM Option
Facility at which the accident/incident occurred*

AviaryTrailsChildren's CenterOff Property
Location of accident/incident
Were the police called?*

YesNo
Name of responding officer
Was an injury or illness involved?*

YesNo
Was 911 (EMS) called?*

YesNo
Contact Information for Individuals Involved in Accident/Incident*
Contact Information for Witness(es)
Describe in detail the accident/incident*
What rules, if any, were violated? Had a previous warning been given and by whom?*
Have the contributing factors been addressed? If so, how?*
What first aid was provided and by whom?*
Type "N/A" if no first aid was provided. If first aid was provided to more than one individual, use names to identify who received first aid.
How many individuals were injured/ill?

123
Injured/Ill Individual #1 Name*

First NameLast Name
Area of Injury - Individual 1*

AnkleArmBackChestEarElbowEyeFaceFingerFootGroinHandHeadHipKneeLegMouthNeckNoseRibsShoulderStomachToothWristN/AOther
Result of Injury*

No visible injuryAbrasion/ Cut/ LacerationAllergic Reaction (Suspected)BurnBleedingBruiseChokingChemical ExposureDizzinessInsect Bite/StingLoss of ConsciousnessNauseaPainPrevious ConditionPunctureRednessSwellingN/AOther
Was this individual transported by EMS?*

YesNo/Declined Transport
Was a family member or individual designated by the injured/ill #1 contacted?*

YesNo
Family member or other designated individual contacted for individual #1*
Injured/Ill Individual #2 Name*

First NameLast Name
Area of Injury - Individual #2*

AnkleArmBackChestEarElbowEyeFaceFingerFootGroinHandHeadHipKneeLegMouthNeckNoseRibsShoulderStomachToothWristN/AOther
Result of Injury - Individual #2*

No visible injuryAbrasion/ Cut/ LacerationAllergic Reaction (Suspected)BurnBleedingBruiseChokingChemical ExposureDizzinessInsect Bite/StingLoss of ConsciousnessNauseaPainPrevious ConditionPunctureRednessSwellingN/AOther
Was individual #2 transported by EMS?*

YesNo/Declined Transport
Was a family member or individual designated by the injured/ill #2 contacted?*

YesNo
Family member or other designated individual contacted for individual #2*
Injured/Ill Individual #3 Name*

First NameLast Name
Area of Injury - Individual #3*

AnkleArmBackChestEarElbowEyeFaceFingerFootGroinHandHeadHipKneeLegMouthNeckNoseRibsShoulderStomachToothWristN/AOther
Result of Injury - Individual #3*

No visible injuryAbrasion/ Cut/ LacerationAllergic Reaction (Suspected)BurnBleedingBruiseChokingChemical ExposureDizzinessInsect Bite/StingLoss of ConsciousnessNauseaPainPrevious ConditionPunctureRednessSwellingN/AOther
Was individual #3 transported by EMS?*

YesNo/Declined Transport
Was a family member or individual designated by the injured/ill #3 contacted?*

YesNo
Family member or other designated individual contacted for individual #3*
You may upload support documentation. Do not upload pictures without the consent of the individual (except for trespassing cases).

Cancelof
Should be Empty: