Sample Incident/Accident Report Form

ACCIDENT/INCIDENT REPORT FORM

Date of incident: ______Time: ______AM/PM

Type of Incident (Circle one): Facility Emergency Weather Emergency Accident/Injury Fire/Chemical Emergency Drowning Spinal Injury Details of incident:

Actions Taken:

For injury reporting only:

Name of injured person: Address: Phone Number(s): Date of birth: ______Male ______Female ______

Who was injured person? ______

Injury requires physician/hospital visit? Yes ___ No _____ Name of physician/hospital: Address: Physician/hospital phone number:

Signature of injured party ______Date *No medical attention was desired and/or required.

Signature of injured party Date

Return this form to Safety Chair within 24 hours of incident.

0a12db9e20458d2fba28da7f4507794c.doc 1 3-Aug-17 ACCIDENT/INCIDENT REPORT FORM USA Diving or USA Swimming Incident forms must be fill out within 3 hours of the incident and filed with USA Diving or USA Swimming respectively.

0a12db9e20458d2fba28da7f4507794c.doc 2 3-Aug-17