Report of Accident / Incident Form

Report of Accident / Incident Form

Use this form if an incident occurs during a Girl Scout activity or event.
Person Submitting Form*

First NameLast Name
Email*
example@example.com
Reporting an...*

AccidentIncident
Name of Person(s) Involved*
Immediate Supervisor / Person in Charge*
Date and Time of Accident / Incident*

MonthDayYear
Date
Hour MinutesAM/PM Option
Location of Accident / Incident*
Accident Reported To*
Date of Investigation

MonthDayYear
Date
Cause of Injury*
Part of Body*
Nature of Injury*
What happened?*
Why did it happen?*
What corrective action could be taken?*
Additional Information / Comments
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: