Nurse Accident Action Sheet
This is for all actionable events for treatment of a camper on the
Indiana Conference And Training Center, 1900 E. Broadway St. Fortville, IN 46040. 317-485-5984
First and Last Name Of Injured *
Your answer
Type of Injury *
Description of Accident or Illness *
Your answer
Describe circumstances surrounding the incident.
Your answer
What First Aid action was used? *
Your answer
When was this done?
Your answer
Who provided the aid?
Your answer
Reporting Nurses' Name *
Your answer
Reporting Nurses' Email address: *
Your answer
Camp Official who received report:
Your answer
If it was an accident with injury, what steps would you recommend to minimize a reoccurrence of the situation? - Filled out by nurse or camp official
Your answer
Did Injury require Hospital visit? *
Was the child sent home *
If Hospital Visit required, fill out the second page.
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