Risk Management Incident Report Form
Instructions: This form must be completed immediately following any incident, accident, or injury that occurs at a chapter event or activity. Submit to the Risk Management Committee Chairman within 24 hours.
Event Information
Event Name
*
Event Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Event Location Address
*
Event Chairman
Approximate Number of Attendees
*
Incident Information
Date of Incident
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Incident
*
Location of Incident. Be specific
*
Person(s) Involved
Name
*
Phone Number
Format: (000) 000-0000.
Person Involved Email Address
example@example.com
Role at Event (Guest, Member, Vendor, etc.)
*
Age (if under 18 note "Minor")
*
Description of Incident
Description of Incident Type of Incident (check all that apply):
*
Slip and Fall
Trip and Fall
Medical Emergency
Property Damage
Other
Detailed Description of What Happened
*
Witness Information
Witness Name
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Witness Statement
Response and Actions Taken
First Aid Administered?
*
Please Select
Yes
No
Emergency Services Contacted (911)
*
Please Select
Yes
No
Was the individual able to continue participation?
*
Please Select
Yes
No
Additional Actions Taken
Follow-Up Required
Was site/property owner notified?
*
Please Select
Yes
No
Is additional reporting needed?
*
Please Select
Yes
No
Explain
Report Submitted By
Name
*
Role in Chapter
*
Phone Number
*
Format: (000) 000-0000.
Submitter Email Address
example@example.com
Date Submitted
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
Preview PDF
Submit
Should be Empty: