New Orleans JCC Incident Report
This form is to be used by Employees of the New Orleans Jewish Community Center to report all work related injuries, illnesses, "near miss" events (which could have caused an injury or illness.) or any event that concerns you as a staff member.  This helps the organization identify and correct hazards before they cause serious injuries. This form shall be completed within 24 hours of the incident.
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I am reporting a(n): *
Incident Reported By (your full name): *
Your Job Title: *
JCC Supervisor:
Which JCC Campus did this incident occur at? *
Date and Time of Incident: *
Location of Incident: *
What type of incident was this considered: *
Injured Party Name: *
Parent/Guardian of Injured Party (if they are a minor)
Injured Party Cell Phone or Contact Phone Number: *
Injured Party Date of Birth: *
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Description of events leading up to and details of illness/injury/event: *
Please detail any treatment provided (and by whom): *
Please list any other JCC staff or JCC members (full names and contact phone number) who were involved in this incident (helped provide care, witnessed the incident, etc) *
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