Report of Accident / Incident Form
Use this form if an incident occurs during a Girl Scout activity or event.
Person Submitting Form
*
First Name
Last Name
Email
*
example@example.com
Reporting an...
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Accident
Incident
Name of Person(s) Involved
*
Immediate Supervisor / Person in Charge
*
Date and Time of Accident / Incident
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-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Accident / Incident
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Accident Reported To
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Date of Investigation
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Cause of Injury
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Part of Body
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Nature of Injury
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What happened?
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Why did it happen?
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What corrective action could be taken?
*
Additional Information / Comments
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: