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Fillable Printable Standard Incident Report Form

Fillable Printable Standard Incident Report Form

Standard Incident Report Form

Standard Incident Report Form

Incident Report Form
Report any incident including injury, property damage, or youth protection event:
1. Immediately following the incident, call the Council Office at ______________
2. Follow up by immediately completing and faxing this form to council at ______________
PLEASE PRINT CLEARLY
UNIT INFORMATION
Unit: Chartering Organization:
INFORMATION ON PERSON IN CHARGE OF THE GROUP
Name:
Address:
Home: Work:Phone
numbers:
Fax: E-Mail:
INFORMATION ON THE INCIDENT
Nature of the activity:
Place of the activity:
Date of the incident: Time of the incident:
Exact location of the incident:
Weather Conditions (if applicable):
Name of Leader in charge at the time:
Description of incident (if vehicle involved, attach owner, driver, registration info on separate page.)
Witness Name: Home Phone: Work Phone:
Witness Name: Home Phone: Work Phone:
COMPLETE ONLY IF THIS INCIDENT WAS REPORTED TO THE POLICE
Police Station Name, Number:
Police Station Address:
Name and Phone Number of Officer in Charge:
INFORMATION ON INJURED PERSON OR OWNER OF DAMAGED PROPERTY
Name: Birth date:
Address:
Phone Numbers: Home: Work:
Unit: Chartering Organization:Complete this section if
this person is a
registered member:
Youth / Adult (Please circle one)
Please describe nature
of injury or property
damage
Complete if applicable: Name of doctor consulted: Phone:
Complete if applicable: Name and address of hospital or clinic: Phone:
REPORTING DETAILS
Print full name:
Position in Scouting:
Street Address:
Town, State, Zip:
Telephone (Home) (work)
Fax: Email:
This report must be
signed by a currently
registered Scouting
member or a current
employee.
Fax to council office
when competed; send
original to
______________Council,
________________________,
________________________
Signature: Date:
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