Accident/ Incident Form
Please fill out 1 form on each incident or person.
Location of Incident
Address of Incident
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date
-
Month
-
Day
Year
Date
Name of Person Involved
First Name
Middle Name
Last Name
Age
blanks
Sex
blank
T Staff
Visitor
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Name of Parent/Guardian (if minor)
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Name/Addresses of Witnesses (You may wish to attach signed statements.)
Type of incident
Illness
Accident
Other (describe)
If you selected 'Other' please describe below
Date of Incident/Accident
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Describe the sequence of activity in detail including what the (injured) person was doing at the time
Where occured? (Specify location, including location of injured and witnesses. Use diagram/descriptions to locate persons/objects.)
Was the injured person participating in an activity at the time of injury?
Yes
No
If so, what activity?
Any equipment involved in accident?
Yes
No
If so, what kind?
What could the injured have done to prevent injury?
Emergency procedures followed at the time of incident/accident
By whom were emergency procedures followed by? (full name)
Additional Notes:
Submitted by
First Name
Last Name
Position/Title
Date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: