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...
*
Accident
Incident
Name of Person(s) Involved
*
Immediate Supervisor / Person in Charge
*
Date and Time of Accident / Incident
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Accident / Incident
*
Accident Reported To
*
Date of Investigation
-
Month
-
Day
Year
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
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: