Accident/Incident Report

Please fill out and submit this form within 24 hours of the occurrence. Note that you must enter a response in each field (even if it is “n/a” or “unknown”) or the form will fail.  Thank you!

Name of person involved:
Date of occurrence:
Time of occurrence:
Location of occurrence:
Witnesses:
Detailed description of occurrence:
Assessment of injury:
Response. Describe treatment administered. Detail whom, how, when and where:
Transportation. If injured party was transported for further assessment/treatment, who did the transporting?
Name of parent/designated emergency party notified:
Time of notification:
Submitted by: