HTML Preview Blank Accident Incident Report Form page number 1.
Accident/Incident Report
Attorney/Client Privileged Document
Form
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Agency name Today’s date
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Date of incident (mm/dd/yyyy) Time of incident (hh/mm a.m./p.m.)
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Name of person completing report Title of person completing report
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Business phone number Business email
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Is there an address for this location? [ ] Yes [ ] No [ ] Unknown
If yes, please provide the following:
Street address
City State Zip code
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If an employee was injured, please submit the form for an Employee Injury (Form 04) type of incident.
Was a person injured? (Ex. patron, citizen, participant, volunteer) [ ] Yes [ ] No [ ] Unknown
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Is injured person an agency volunteer? [ ] Yes [ ] No [ ] Unknown
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Did injured person make any statements? [ ] Yes [ ] No [ ] Unknown
If yes, what did injured person say?
Describe the injury (affected body part and type of injury; Ex. contusion, bruise, laceration, sprain, break, etc.)
If yes, please provide the following information:
Last name First name
Address
City State Zip code
Home phone # Work phone # Cell phone #
Age Sex [ ] Male [ ] Female
Location (Specify the exact type of location/facility where injury occurred. Ex. maintenance garage, sports eld, aquatic
outdoor, golf course, etc.)
Primary location (Specify exact location. Ex. lap pool, cart storage, classroom, pavilion)
Name of the location (park, pool, community center; Ex. Smith Pool, Johnson Community Center) or nearest intersection
where the incident occurred.
How did the incident occur? (Provide a brief, factual description; do not speculate on fault, etc.)
BODILY INJURY
Program Supervisor:
Date:
Superintendent:
Date:
Risk Manager:
Date: