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Incident Reporting Tool

(Events or allegations of injury, illness, or property damage, including employment and directors and ofcer’s issues)

General Incident Details

*Required Fields

*Incident Date: ________________________________ Incident Time (in 24-hour format): ______________________________________

*Report Date: _______________________________________________________________________________________________________

Date Reported to Council/BSA Location: ______________________________________________________________________________

Reported by Name: _________________________________________________________________________________________________

Reported by Primary Phone: ______________________________ Reported by Secondary Phone: _____________________________

Incident City: _____________________________________ *Incident State: ______________ Incident Zip Code: ___________________

*Description of Incident (clear/concise/complete facts):

Was an Agency or Authority Notied? ❏ Yes ❏ No Whom: ____________________________________________________

Injury/Illness/Damage Information

*Claimant Name: ____________________________________________________________________________________________________

Claimant Address: __________________________________________________________________________________________________

Claimant City: ____________________________________ *Claimant State: _____________ Claimant Zip Code: __________________

Claimant Primary Phone: ___________________________ Claimant Secondary Phone: _______________________________________

Claimant Email: _____________________________________________________________________________________________________

Claimant Date of Birth: _________________________________________ Age of Claimant: _____________________________________