FRIENDLY PINES CAMP INCIDENT REPORT FORM

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Incident Date *

YYYY

First Name
*

Last Name *

Summer Season *

Incident Time *

Time

Claimant Type *

Camper

Staff

Guest

Volunteer

Other:

Nationality *

Domestic

International

International Staffing Agency?

(if reporting for International Staff)

Camp America

Camp Leaders

ICCA

Other:

Clear selection

Date of Birth *

YYYY

Parent Full Name *

(if reporting for camper)

Parent Address *

(if reporting for camper)

Names & Addresses of Witnesses *

Incident Description *

Please estimate the severity of the incident. *

Very Low

Low

Moderate

High

Very High

Other:

Any notes on the severity of the incident?

Type of Incident *

Accident

Illness

Dental

Behavioral

Other:

Required

Any notes on the type of incident?

Incident Characteristics

Location *

"Other" Location

Cause of Incident *

"Other" Cause of Incident

Body Part Affected *

"Other" Body Part Affected

What type of injury? *

"Other" Injury Type

What type of illness? *

"Other" Illness Type

Activity *

"Other" Activity

Treatment

Where was treatment given? *

Camp Health Center

Doctor's Office

Hospital

At Accident Site

Other:

Required

Health Center: Date & time of treatment (MM/DD/YYYY)

Health Center: first and last name of person(s) who treated

Doctor's Office: Date & time of treatment (MM/DD/YYYY)

Doctor's Office: first and last name of person(s) who treated *

Hospital: Date & time of treatment (MM/DD/YYYY)

Hospital: first and last name of person(s) who treated *

At Accident Site: Date & time of treatment (MM/DD/YYYY)

At Accident Site: first and last name of person(s) who treated *

Have you been treated for this condition within the past 12 months? *

Yes

Other:

Required

If so, please provide the name of physician? *

Was Emergency Transportation used? *

Ambulance

Helicopter

Other:

Required

Explain "other" emergency transportation method *

Missed time from camp? *

Yes

Other:

Released to: *

Home

Camp Activities

Health Center

Other:

Required

Were parents notified? *

(if reporting for camper)

Yes

Other:

Parent Contact & Reception: *

(if reporting for camper)

We have contacted the parents and they are pleased with how the incident was handled.

We have contacted the parents and they are concerned with how the incident was handled.

Other:

Required

This form was submitted by:

First Name *

Last Name *

Title *

Phone Number *

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