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Incident Report Form
Step
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Incident Date & Time
Type of Injury
(Required)
Injury
Non-Injury
Date of Incident
MM slash DD slash YYYY
Time of Incident
Hours
:
Minutes
AM
PM
AM/PM
Involved Parties
Who is involved/injured?
Employee
Camper
Guest
Volunteer
Other
Other Involved/Injured
Would you like to discuss a Workers Compensation claim?
Yes
No
Please complete this form and then call/email or visit the HR office and speak with Krista Ashmen and see our camp nurse for treatment.
Type of Non-Injury
Camper Departure
Facility (broken stairs, handrail, etc.)
Traffic (parking, fender bender, etc.)
Natural Event (tree fall, flood, etc.)
Retail
Fire
Other
N/A
Other Non-Injury Type
Program
Program
Creek Program
Guest Group
Outdoor Science
Lone Star Lights
Other
N/A
Other Program
Location
Location
The Wild
Creekside
Lakeview
Lake Livingston
Offsite
Other
Offsite Location
Other Location
Location Details
Please specify or describe the element, activity or facility related issue
Involved or Injured Person Details
Name
First
Last
Age
Phone
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Involved Party Email
Is the involved or injured person a minor?
(Required)
Yes
No
Parent/Guardian Information
Parent/Guardian Name
First
Last
Parent/Guardian Phone
Parent/Guardian Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Parent/Guardian Email
Parent/Guardian Notification
Has the Parent/Guardian beed notified?
Yes
No
Date
MM slash DD slash YYYY
Time
Hours
:
Minutes
AM
PM
AM/PM
Notified by
First
Last
If not notified, why?
Witnesses or Involved Parties
Additional Witnesses or involved parties
List additional persons involved and describe involvement.
Incident Details
Describe incident with as many details as possible
(Health Staff: Provide patients description of injury/incident)
Action Taken
Action Taken
Ex: Called tow truck, referred to health center, applied Bandaid, called CPS, etc.
Report Completion
Incident Report Completion
(Required)
I agree that I have been as thorough as possible describing the incident or injury on this form.
Your Name
First
Last
Position
Date
MM slash DD slash YYYY
Phone
Email
Signature
