Incident Report
Date of Report:
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Reported By:
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Date of Incident:
MM
/
DD
/
YYYY
Time of Incident:
Time
:
Name of Injured Person:
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Injury Type:
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Required Medical Care:
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Treatment Given:
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Specific Area of the Body Affected:
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Equipment Involved:
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Detail of the Incident:
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Parents Contacted:
City:
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State:
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Zip Code:
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Specific Location of Incident:
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Supervisor Name:
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Supervisor Signature:
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