Fillable Printable 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:

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: