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Accident/Injury Report
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* Indicates required question
Email
*
Your email
Date of Report
*
MM
/
DD
/
YYYY
Date of Accident
*
MM
/
DD
/
YYYY
Time of Accident
*
Time
:
AM
PM
Name of Injured Person
*
Your answer
Team Name
*
Your answer
Age
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Contact Number
*
Your answer
Nature/Extent of Accident / Injury
*
Your answer
Accident/Injury
*
Your answer
How did the Accident/Injury Occur?
*
Your answer
Other Comments or Observations?
*
Your answer
Was Treatment Given?
*
Yes
No
If yes, indicate treatment given
*
Your answer
Treatment given by
*
Your answer
Certification
*
None
EMT
Paramedic
Required
Witness
*
Your answer
Witness Phone Number
*
Your answer
Disposition
*
Stayed at park
Emergency Room
Doctor's Office
Other:
If transported, how?
*
Parent
Relative
Ambulance
Other:
Parents notified?
*
Yes
No
If parents were notified, by whom?
*
Your answer
Parents Comments
*
Your answer
Is an insurance claim to be filed?
*
Yes
No
If yes, date sent in?
*
MM
/
DD
/
YYYY
Was the Accident/lnjury avoidable?
*
Yes
No
Other:
If yes, explain:
*
Your answer
Were any safety violations involved?
*
Yes
No
If yes, please explain:
*
Your answer
Name of Person Completing Report
*
Your answer
Date of Person Completing Report
MM
/
DD
/
YYYY
Signature of Person Completing Report
*
Your answer
Name of Safety Director
*
Your answer
Date of Safety Director
*
MM
/
DD
/
YYYY
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