Accident/Incident Report AFFECTED/INJURED PERSON * First Name Last Name Affected/Injured Person Phone (###) ### #### PARENT/GUARDIAN (if individual is a minor) First Name Last Name Parent/Guardian Phone (###) ### #### ACCIDENT/INCIDENT DETAILS * Date of Accident/Incident MM DD YYYY Location * Time Accident/Incident Description * Please describe the accident/incident. Injury/Damage Description Please describe the injury or damage caused by the accident/incident. Treatment or Care Given: Was treatment or care given to the individual? Treatment or Care Given By: Who gave the treatment or care to the individual? Following Treatment or Care... How did the individual respond to treatment or care? Names of Individuals Notified: Who was notified of this incident? WITNESS INFORMATION * First Name Last Name Witness Phone * (###) ### #### FORM SUBMISSION * I attest that this constitutes my legal electronic signature on this form. First Name Last Name Date * MM DD YYYY Email Address * Phone Number (###) ### #### Thank you!
