Report of Incident - Visitor
School building where incident occurred ______Date ______
Injured person______Address______
Street City State Zip
Parent ______Address ______Phone ______
Day Evening
General Information
Describe exactly what happened. ______
______
______
______
Medical Information
Describe the injured party’s condition and any first aid. Was first aid given? ______Blood-borne exposures? ______
______
______
Further medical attention? ______If so, where and by whom: ______
Was parent / guardian / emergency contact notified? ______If so, when? ______
Who was called and what was the outcome? ______
With whom did the injured party leave the site? ______
Witnesses (indicate staff [s], participant [p], or volunteer [v])
S P V Name Age Phone Address City State Zip
______
______
______
Incident Management
Signature of injured person (18 and over) Date
Employee Filing Report ______Position Date ___
Parent Signature Date
Administrator Reviewing Report ______Position Date
Follow-up required by Supervisor or Building Principal within 48 hours of the incident
Follow up date ______And by whom? ______
Detail status.
Please check one and only one box in each of the following sections
Specific Location of Incident
__ Aquatic: Main Pool__ Aquatic: Exercise Pool__ Meeting Room __ Locker Room
__ Lobby / halls / stairs__ Athletic Field __ Parking lot / Garage __ Cabin
__ Play structure or area: interior __ Running track__ Gymnasium__ Restroom
__ Playground (i.e., with equipment) __ Childcare site__ Classroom__ Cafeteria
__ Media Center__ Bus__ Other ______
Program
(indicate name)______
__ Aquatics __ Childcare__ Adult Fitness__ Special Events
__ Field Trips__ 7th grade Camp__ Non-sport activities __ Sports: Informal
__ Sports: Adult__ Sports: Youth__ Outdoor Education __ Senior program / activity
__ Community Ed class__ School Session__ Athletic Event/Game
__ Ski Club__ Other ______
General Activity
__ Aquatics: exercise class __ Free / unstructured play __ Skiing / snowboarding__ Volleyball
__ Aquatics: family / open swim __ Games / structured play __ Soccer__ Football
__ Aquatics: lap swim __ Dance / Gymnastics __ Baseball / Softball / T-ball__ Basketball
__ Aquatics: lessons __ Dressing / Undressing __ Theft / robbery__ Track / Cross Country
__ Aquatics: team (incl. practice)__ Transportation__ Exercise: Free weights__ Exercise: Run / walk
__ Band/Choir – Practice/Event__ Classroom Instruction__ Exercise: Strength equip
__ Playground equipment __ Other ______
Specific Action
__ Aggressive behavior of / by __ Exertion __ Inappropriate touch __ Struck by / against
__ Caught in, by, or between __ Fall (from, onto, into, or against)__ Inhale / ingest __ Contact with / exposure to
__ Verbal attack / taunt / teasing__ Horseplay__ Pushed/pulled/bumped__ Inappropriate Language
__ Handle / use / touch__ Participation / playing __ Other ______
Source of Injury
__ Aquatics: deck __ Blood / body fluids __ Floor / Ground __Person (another)
__ Aquatics: equipment __ Door__ Furniture__Self
__ Aquatics: sides / bottom__ Environment: sun, heat, etc. __ Insect / animal __Wall / vertical surface
__ Aquatics: water, body of__ Equipment: Exercise __ Locker / cabinet __ Object (ball / bat / toy / etc.)
Equipment: Playground__ Other ______
If the equipment or property was defective, who was notified for repair or follow up:
Person Notified: ______By whom: ______date _ __
What action was taken / date of repair completed:
Describe: ______
Date: ____ _
Apparent Injury
__ Abrasion / scratch __ Bruise / contusion __ Fear / intimidation __ Seizure / dysfunction
__ Aquatic distress __ Burn / blister __ Fracture / break__ Sprain / strain
__ Bite / sting __Cramp__ Irritation / reaction __ Vomiting
__ Bloody / hemorrhage__ Cut / puncture __ Jam__ No visible / apparent injury
__ Breathing shortened / impaired __ Dislocation __ Pain / soreness __ Dizziness / Unconscious __ Pinch/Crush __Other ______
Body Part
please check if applicable: O right O left O upper O lower
__ Arm __ Leg __ Shoulder __ Back __ Face __ Head __ Mouth / lips / teeth
__ Hand / finger__ Foot / toe __ Chest __ Buttocks __ Ear __ Neck __ Mind / psyche
__ Wrist __ Ankle __ Stomach __ Hip__ Eye__ Heart __ None / not applicable
__ Elbow__ Knee __ Side __ Groin __ Nose__ Lungs __ Other ______
Forward this completed form to the Executive Director of Business, Operations & HR, within 48 hours of this incident / injury.
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