Accident/Incident Report
Name of employee completing report
*
First Name
Last Name
Date and time of accident/incident
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Facility at which the accident/incident occurred
*
Aviary
Trails
Children's Center
Off Property
Location of accident/incident
Were the police called?
*
Yes
No
Name of responding officer
Was an injury or illness involved?
*
Yes
No
Was 911 (EMS) called?
*
Yes
No
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?
1
2
3
Injured/Ill Individual #1 Name
*
First Name
Last Name
Area of Injury - Individual 1
*
Ankle
Arm
Back
Chest
Ear
Elbow
Eye
Face
Finger
Foot
Groin
Hand
Head
Hip
Knee
Leg
Mouth
Neck
Nose
Ribs
Shoulder
Stomach
Tooth
Wrist
N/A
Other
Result of Injury
*
No visible injury
Abrasion/ Cut/ Laceration
Allergic Reaction (Suspected)
Burn
Bleeding
Bruise
Choking
Chemical Exposure
Dizziness
Insect Bite/Sting
Loss of Consciousness
Nausea
Pain
Previous Condition
Puncture
Redness
Swelling
N/A
Other
Was this individual transported by EMS?
*
Yes
No/Declined Transport
Was a family member or individual designated by the injured/ill #1 contacted?
*
Yes
No
Family member or other designated individual contacted for individual #1
*
Injured/Ill Individual #2 Name
*
First Name
Last Name
Area of Injury - Individual #2
*
Ankle
Arm
Back
Chest
Ear
Elbow
Eye
Face
Finger
Foot
Groin
Hand
Head
Hip
Knee
Leg
Mouth
Neck
Nose
Ribs
Shoulder
Stomach
Tooth
Wrist
N/A
Other
Result of Injury - Individual #2
*
No visible injury
Abrasion/ Cut/ Laceration
Allergic Reaction (Suspected)
Burn
Bleeding
Bruise
Choking
Chemical Exposure
Dizziness
Insect Bite/Sting
Loss of Consciousness
Nausea
Pain
Previous Condition
Puncture
Redness
Swelling
N/A
Other
Was individual #2 transported by EMS?
*
Yes
No/Declined Transport
Was a family member or individual designated by the injured/ill #2 contacted?
*
Yes
No
Family member or other designated individual contacted for individual #2
*
Injured/Ill Individual #3 Name
*
First Name
Last Name
Area of Injury - Individual #3
*
Ankle
Arm
Back
Chest
Ear
Elbow
Eye
Face
Finger
Foot
Groin
Hand
Head
Hip
Knee
Leg
Mouth
Neck
Nose
Ribs
Shoulder
Stomach
Tooth
Wrist
N/A
Other
Result of Injury - Individual #3
*
No visible injury
Abrasion/ Cut/ Laceration
Allergic Reaction (Suspected)
Burn
Bleeding
Bruise
Choking
Chemical Exposure
Dizziness
Insect Bite/Sting
Loss of Consciousness
Nausea
Pain
Previous Condition
Puncture
Redness
Swelling
N/A
Other
Was individual #3 transported by EMS?
*
Yes
No/Declined Transport
Was a family member or individual designated by the injured/ill #3 contacted?
*
Yes
No
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).
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