Troop and Group Accident/Incident Report Form

Troop and Group Accident/Incident Report Form

(Includes Medical Report of Accident)
General Information
Report Submitted by*

First NameLast Name
Submitter email*
example@example.com
Submitter phone number*

Area CodePhone Number
Submitter postion*
Date of Accident/Incident*

MonthDayYear
Hour MinutesAM/PM Option
Name of Property/Location:*
Program/Activity:*
Describe the sequence of activity in detail (If injury, include what the injured person was doing at the time)*
Names/Addresses of those involved and any witnesses (attach signed statements at end)*
Was the Service Unit Manager notified?*

YesNo
Was any equipment involved in the accident/incident:*

YesNo
If yes, what equipment?
Describe any contact made with/by media regarding this situation if applicable
Report of Injury
Were there injuries?*

YesNo
Name of Injured:*
Indicate Names of those Injured.
Birth Date*

MonthDayYear
Address of Injured:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*

Area CodePhone Number
Home Phone Number*

Area CodePhone Number
Emergency procedures followed at time of accident/incident:*
What could injured have done to prevent the accident/incident?*
Please record above details for any additionally injured or upload file of details below. Include name, address, contact information and details related to the injury/treatment.
Additionally injured information

Cancelof
Medical Report of Accident

If Injuries, please complete the below
Name of First Aider*

First NameLast Name
Phone Number*

Area CodePhone Number
Report Submitted By:*

First NameLast Name
Position:*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Was parent/guardian/spouse notified?

YesNoIn writingBy phoneOther
Who notified parent/guardian/spouse?
Name and Title
When?
Where was treatment given?

At the site of the accident/incidentIn the camp health centerAt the doctor's/hospital
At accident/incident site
Treatment Given: By Whom? When?
In Camp Health Center
Treatment Given: By Whom? When?
At Doctors/Hospital
Treatment Given: By Whom? When?
Treatment

In-PatientOut-Patient
Were Parents present?

YesNo
Name of Physician:

First NameLast Name
Date & Time of Release:

MonthDayYear
Hour MinutesAM/PM Option
Released to:

Camp Health CenterHomeOther
For Minors (Under 18 years of age)
Were minors involved?*

YesNo
Was the Parent/Guardian notified?

Yes.No.
Name of Parent/Guardian:
Indicate Names of those Injured.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Please record above details for any additional minors below or upload file of details below
Additional Minor details

Cancelof
Additional Files and Notes
Attach statements from any witnesses

Cancelof
Additional notes or comments (if needed)
Should be Empty:

Troop and Group Accident/Incident Report Form

Medical Report of Accident

For Minors (Under 18 years of age)

Additional Files and Notes