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Incident Report Form
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Fill out for a guest.
Fill out for a Tejas Staff Member.
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Staff Incident Report
Injured Person Information
Name
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First Name
Last Name
Sex
Please Select
Male
Female
Birth Date
Please select a month
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Day
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Year
Employee Position
Incident Information
Date and Time of Injury
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Type of injury
Please Select
Skin
Muscle
Joint
Bone
Illness
Other
If Other:
Part of Body Injured or Exposed
Please Select
Head/Face
Neck
Arms
Hands
Torso
Groin
Legs
Feet
Other
If Other:
*
How and Why Injury/Illness Occurred (Only state facts, not opinion)
*
Was Employee Doing Their Regular Job?
*
Yes
No
Worksite Location of Injury
*
If Other
*
Cause of Injury (fall, tool, machine, etc.)
Please Select
Fall
Tool
Vehicle
Nature
Equipment
Other
Please Specify
Was There a Witness
Yes
No
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Injured Person Information
Name
*
First Name
Last Name
Birth Date
*
/
Month
/
Day
Year
Date
Age
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
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16
17
18
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Sex
Please Select
Male
Female
Phone Number
*
Hometown
Group Name / Event
With Whom did you attend?
Was the injured person a minor?
Yes
No
Name of Parent or Guardian
Relationship to injured minor
Phone Number
Hometown
Were the parents of the injured notified
Yes
No
Parents response or instructions:
Incident Information
Type of incident
Please Select
Behavioral
Accident
Illness
Other
If Other
Date and Time of incident
*
-
Month
-
Day
Year
Date Picker Icon
Hour Minutes
AM
PM
AM/PM Option
Location
If Other
Equipment involved
Type of injury
Please Select
Skin
Muscle
Joint
Bone
Illness
Other
If Other
Possible pre-existing condition?
Yes
No
Specific sequence of events. (Please list only the facts)
*
What treatment was given?
*
By whom was the treatment given?
*
Was the injured moved?
Yes
No
How and by whom was the injured moved?
Was medication given?
Yes
No
What medication was given and by whom?
Was there any reason the injured departed from Tejas?
Was any care refused and for what reason?
Was 911 Called
Yes
No
By whom?
At what time
Hour Minutes
AM
PM
AM/PM Option
Was Tejas Leadership notified
*
Yes
No
Name of Leadership?
Was a group leader notified
Yes
No
Name of group leader?
Condition of injured at time of release
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Witness Information
First Name
*
Last Name
*
Phone Number
*
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Form Submitted By:
By checking this box I agree to use an electronic signature to verify this information and that this signature is my own.
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Injured
Witness
Other
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