Accident Report Form

D IOCESE OF H OUMA - T HIBODAUX - I NCIDENT R EPO R T F ORM

LOCATION INFORMATION Date of this report:

Parish/School or Institution:

Address

City/State

Person Reporting Incident:

Phone number Email

Date of accident: Time: AM/PM

Injured Person was: Student / Volunteer / Parishioner / Other

Name of Injured Person:

Address:

Phone Number(s):

Date of Birth: Social Security #

Where did Accident Occur?: Were photos taken? Yes / No

What was injured person doing at time of injury?

Type of injury:

Details of incident:

Injury requires physician/hospital visit? Yes / No Was Ambulance Called?

Who call ambulance? Phone Name of physician/hospital: Address:

Name of witnesses: Phone Phone Phone 03/17/14 Fax report to 985-850-3235