SCC Incident/Accident/Illness Report
Staff/Volunteer: Print and return this completed form to an SCC administrator immediately or submit online
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Email *
Person Filing Report
Name: *
Address: *
Email: *
Phone Number: *
Incident Details
Please fill out to the best of your ability.
Date of Incident: *
MM
/
DD
/
YYYY
Exact Location of Incident: *
Type of Incident: *
Who was involved? *
Description of Incident/Illness/Accident: *
Actions Taken by Staff/Volunteer:
Please Describe what actions were Taken: *
Please Provide Names and Contact Information for Witnesses that May be Contacted: *
Was Law Enforcement Contacted? *
Please Provide Case # (If Known) and a detailed description of the outcome: *
Was Medical Attention Sought? *
Was Treatment Refused? *
Was Medical Transportation Required? *
For SCC Office Use Only
Follow Up:
This Section to be filled out by SCC Administrator/Board of Directors:
Prevention Plan:





Follow-up Review:
A review of the preventive steps taken will be performed 3 months from the initial date filed for effectiveness. If there has not been improved prevention of future incidents, the SCC board of directors and administrator will review the “Actions Taken” section and adjust the action plan until satisfactory resolution is attained.

Has the incident reoccurred since the initial review?
       Yes      NO

Follow-up Reviewer’s Summary:





Printed Name: _____________________________________ Title: _______________________        

Signature: ________________________________________ Date: _______________________

Filing Finished Report:

Signature: _________________________________________ Date: ______________________

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