Fillable Printable Sample Incident Report Form
Fillable Printable Sample Incident Report Form
Sample Incident Report Form
Incident Information Report
(Events or allegations of injury, illness, or property damage including employment and directors and officers issues)
Incident date: _________________ Time: _______________________
Reporting date: _______________ Time: _______________________
Council/BSA location: _______________________________________ Leader Parent Other: ___________________
Reporting person: _________________________________________________________________________________________
Location of incident: ________________________________________________________________________________________
Specific area where incident occurred:
Cause of incident:
Program/event/adventure code: _______________________________________________________________________________
Did the incident occur while transporting to/from an activity? Yes No
Comments:
Individuals Involved (Duplicate if Needed)
Name: __________________________________________________________________________________________________
First Middle Last
Address:_________________________________________________________________________________________________
City State Zip
Home phone: _____________________ Cell phone: ______________________ Work phone: _____________________________
DOB: ___________________________ Age: _______Unit No.:______________ Council: ________________________________
Scouting role: ____________________________________________________________________________________________
Type of injury or property damage: ______________________ Injured body part: _______________________________________
Was medical treatment given at scene?
Yes No Type: _____________________________________________________
Medical disposition (transported to hospital, etc.): ________________________________________________________________
Return this completed form to your council’s designated user for entry into RiskConsole via MyBSA Incident Entry.
Incident Information Report
(Events or allegations of injury, illness, or property damage including employment and directors and officers issues)
Witnesses
Name: __________________________________________________________________________________________________
First Middle Last
Address:_________________________________________________________________________________________________
City State Zip
Home phone: _____________________ Cell phone: ______________________ Work phone: _____________________________
Others
Name: __________________________________________________________________________________________________
First Middle Last
Address:_________________________________________________________________________________________________
City State Zip
Home phone: _____________________ Cell phone: ______________________ Work phone: _____________________________
Property Damage (if applicable)
Property or vehicle make/model/year: __________________________________________________________________________
Color: _______________________ License plate No.:_____________________________________________________________
Driver Contact Information (if applicable)
Name: __________________________________________________________________________________________________
First Middle Last
Address:_________________________________________________________________________________________________
City State Zip
Home phone: _____________________ Cell phone: ______________________ Work phone: _____________________________
Passengers: ______________________ Contact information: _______________________________________________________
Additional information:
Information gathered at scene by: _____________________________________________________________________________
Contact information: ________________________________________________________________________________________
Return this completed form to your council’s designated user for entry into RiskConsole via MyBSA Incident Entry.
680-016
2010 Printing
