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Incident Report

Information of Person Affected

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Person filling out report

Is this being filled out by a person other than the affected party?

Yes

Name

First Name

Last Name

Phone

(###)

###

####

Incident Details

Was the 24/7 Accident Reporting line called?

This number should be called for all incidents.

Yes, this number has been called.

No, this number has not been called.

Date of Incident

YYYY

Time of Incident

Hour

Minute

Second

Incident Description

Describe what caused the incident, what you were doing just before, and what you did after the incident. Be specific--name any objects or substances involved.

Did anyone witness this?

If so, who witnessed this?

Please include full names.

Did you report this incident to anyone?

If not, why not?

If so, to whom did you report it?

Please include their full name and title.

When did you report it?

Injury Section

What part(s) of your body was affected?

Be specific. For example, right elbow, left knee, right index finger, etc.

What type of injury did you experience?

Be specific. For example, bruise, scrape, laceration, pull

Was any first aid provided at the scene?

If yes, what first aid was provided?

Is this an aggravation of a previous injury/symptom?

If yes, when were you last treated for the previous injury?

Have you ever had a similar injury?

If yes, describe your other injury.

Did you or will you seek medical treatment?

If yes, when did you seek medical treatment?

If yes, where did you seek medical treatment?

If no, why did you not seek immediate medical treatment?

Signature

Type your full name below to sign.

I understand that checking this box constitutes the above is a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this form.

I understand.

Today's Date

YYYY