SAMPLE INCIDENT/ACCIDENT REPORT FORM



Accident/Incident Report FormDate of incident: ______Time: _____ am /pm Report prepared by: _____________________ Staff person on duty: ____________________Name of injured person: Address: Phone Number(s):Date of birth (if known): ________________ Age: ______ Male ______Female _______Who was injured person? (circle one) Attendee Visitor Staff person VolunteerType of injury: Details of incident including any treatment given: Witnesses (name & contact info):_________________________________________________________________________________________________________________________________Injury requires physician/hospital visit?Yes ___No _____Name of physician/hospital: Signature of injured party: ________________________________________________________ DateParent / Guardian (If injured party is a minor) _________________________________________ Date*** If no medical attention was desired and/or required, sign below***Signature of Injured Party or Parent / Guardian DateReturn this form to Executive Director or Business Office within 24 hours of incident. ................
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