Contract Instructor Incident Report

Contract Instructor Incident/ Injury Report

Office Phone: (818) 238-5386
This form is to be filled out to document personal injury, property damage, incidents that occur on City property, or are result of actions from a City Employee. If the question does not apply, write N/A. Submit to Contract Class Supervisor within 24 hours.
Instructor Information
Instructor Name:
Business Name (if applicable):
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Camp/Class Information
Camp/Class Title:
Location:
Date of Incident:

MonthDayYear
Date
Time of Incident:

Hour Minutes

AM/PM Option
Incident Information
Name of Person(s) Involved:
Detailed Description of Incident
Were there any injuries?
How did the injury occur?
Witness(es):
Action Taken
Action Taken at Time of Incident:
Who Was Notified When the Incident Occurred?
First Aid Provided:
Administered By:
Medical Attention? Other than first aid)
Police or Paramedics Notified?
Method of Transportation:

Other
Officer on Scene and Police Report Number:
Provide any Additional Information Below:
Signature:
ATTACH ADDITIONAL SHEETS OF PAPER TO INCLUDE SUPPLEMENTAL DETAILS AND TO SUMMARIZE CORRECTIVE STEPS THAT SHOULD BE TAKEN TO PREVENT REOCURRANCE OF THIS ACCIDENT.

Cancelof
Once the Contract Instructor Incident/ Injury Report has been submitted, please email Aacevedo@burbankca.gov and Jhorhn@burbankca.gov to ensure the report has been received.
Should be Empty:

Contract Instructor Incident/ Injury Report