COCHRANE & DISTRICT AGRICULTURAL SOCIETY INCIDENT REPORT FORM

COCHRANE & DISTRICT AGRICULTURAL SOCIETY INCIDENT REPORT FORM
1. Please provide as much detail as possible. Photos are very helpful. 2. Send the completed form to the Ag Society Office within 48 hours. 3. Keep a copy of this form and all photos and attachments for your record
INCIDENT DETAILS
Date of incident*

MonthDayYear
Date
Time*
Date reported*

MonthDayYear
Date
Time*
Location (facility name)*
Additional Named Insured (ANI) group*
Use of facility at time of incident*
Reported by (Name)*
Position*
Phone number of Reporter*
Email of Reporter*
example@example.com
Incident Description
BODILY INJURY
Name of injured person*
Date of birth

MonthDayYear
Date
Phone number(s)*
Address
Description of the Injury*
PROPERTY DAMAGE

Only fill if there was any damage done to property or animals during the incident.
Name of owner
Phone number(s)
Address
Property involved (vehicle, clothing, horse, etc.)
Description of Damage
CONTRIBUTING FACTORS

Note factors such as time of day, weather conditions, lighting, improper footwear, evidence of intoxication, etc.:
CONTRIBUTING FACTORS
WITNESSES

Add information for any witnesses of the incident. If more space is needed, please submit a full witness list to cochraneagsociety@gmail.com.
Name
Address
Phone number(s)
Name
Address
Phone number(s)
Name
Address
Phone number(s)
SUPPORTING INFORMATION
Was this incident reported to the Police?*

YesNo
If the incident was reported to the Police, please continue filling this section. If the incident was not reported, please continue to the bottom of the page.
Police file number
Attach any photographs of the site where the incident occurred:

Browse Files

Cancelof
Name of photographer
Date photographs taken

MonthDayYear
Date
Phone number(s)
Other Notes (additional details or reports can be emailed to cochraneagsociety@gmail.com)
Signature of Reporter

Clear
Should be Empty:

COCHRANE & DISTRICT AGRICULTURAL SOCIETY INCIDENT REPORT FORM

INCIDENT DETAILS

BODILY INJURY

PROPERTY DAMAGE

CONTRIBUTING FACTORS

WITNESSES

SUPPORTING INFORMATION