WTSDA Incident Report

This report is to be used when a incident occurs, including (but not limited to) any of the following events:

* Injury to instructor, student or spectator
* Conflict between students/Parents/Instructors/Staff
* Student / Parent is upset with actions taken by instructors or students.
* Physical damage is incurred to the building or training equipment
* A complaint is received about something that occurred at the event (beyond an administration related occurrence)

Name of Event

e.g., Region 45 Dan Camp

Were there any "incidents" to be reported? Incidents include, but are not limited to, material injuries, disciplinary events, accidents (e.g., slip-and-fall or car accidents while driving official WTSDA vehicles - rented or otherwise - or shuttling personnel during official WTSDA events), damage to facilities, etc.).

Date of Incident

Date

Time Incident Occurred

Hour Minutes

AM/PM Option

Your (the person completing this form) Name

First NameLast Name

Your Email Address

example@example.com

Your School

Your Dan # (if applicable)

Your Rank

Your Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Location of the incident

Please be specific as to the location, not just the event. Ex: Region 45 Tournament, ABC Event Centre, Anytown USA

Was the incident verbally reported to the event director?

To Whom was it reported?

Date and time it was reported to the event director

Names of ALL Students, Parents and/or Instructors Involved (names, ages, genders and schools and instructors)

Rows	Names	Age	Gender	School Affiliation
Students
Parents
Instructors
WTSDA Staff
Other (spectators, etc.)

Description of incident; please note if there were injuries, please provide information related to any first aid that may have been administered (and by whom it was administered) (OBSERVABLE FACTS ONLY; please be detailed)

Actions taken by the WTSDA

Were parents contacted?

Date of contact

Date

Method of contact

Other

Is there anything else that you would like to share? Please refrain from expressing opinions about the incident itself.

Please add any supporting documentation (e.g., pictures, reports of EMTs, copies of ID, etc.), IF ANY

I certify that the information contained in this Incident Report is true and collect to the best of my recollection.