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FAME All Stars Accident / Incident Report
Use this form to report accidents, injuries, medical situations, criminal activities, traffic incidents, or student behavior incidents. Reports should be completed within 24 hours of the event.
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* Indicates required question
Email
*
Your email
SECTION 1: PERSON INVOLVED
Full Name of Injured/Involved Person
*
Your answer
Address of Injured Person
*
Your answer
Phone
*
Your answer
SECTION 2: THE INCIDENT
Date Report Completed
*
MM
/
DD
/
YYYY
Time of Incident
*
Time
:
AM
PM
Location
Your answer
Describe the Incident:
*
Your answer
SECTION 3: INJURES
Requires Physician/Hospital Visit?
*
Yes
No
Describe the injury or any notes regarding next steps.
*
Your answer
SECTION 4: WITNESSES
Please list any witnesses of the incident.
*
Your answer
SECTION 5: MEDICAL SERVICES
Was medical treatment provided?
*
Yes
No
If yes, where?
On site
Hospital
Other:
Clear selection
SECTION 6: PERSON FILING REPORT
Staff Member Completing Report
*
Your answer
Staff Phone Number:
*
Your answer
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