Preview Incident Information Report

Incident Information Report

(Events or allegations of injury, illness, or property damage, including employment and issues with directors and ofcers)

Incident date: ___________________Time: __________________________

Reporting date: _________________Time: __________________________

Council/BSA location: ___________________________________________ ❏ Leader ❏ Parent ❏ Other: _____________________

Reporting person: ___________________________________________________________________________________________________

Location of incident: _________________________________________________________________________________________________

Specic area where incident occurred:

____________________________________________________________________________________________________________________

Cause of incident:

____________________________________________________________________________________________________________________

Program/event/adventure code: ______________________________________________________________________________________

Did the incident occur while transporting to/from an activity? ❑ Yes ❑ No

Comments:

____________________________________________________________________________________________________________________

Individuals Involved (Duplicate If Needed)

Name: ______________________________________________________________________________________________________________

First Middle Last

Address: ___________________________________________________________________________________________________________

City State Zip

Home phone: _______________________Cell phone: _________________________Work phone: ________________________________

DOB: _______________________________Age: _______Unit No.: _______________Council: ____________________________________

Scouting role: ______________________________________________________________________________________________________

Type of injury or property damage: ________________________Injured body part: ___________________________________________

Was medical treatment given at scene? ❑ Yes ❑ No Type:____________________________________________________________

Medical disposition (transported to hospital, etc.): ______________________________________________________________________

Return this completed form to your council’s designated user for entry into RiskConsole via MyBSA Incident Entry.

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