Get Incident Report Form

Accident/Incident Report Form FM 01 Developed by the American Camping Association Fill out 1 on each incident or person Camp Name Date Address Street Number City State Name of person involved Age Sex Last Frt is Middle Camper Zip Staff Visitor E L P M A S Address Phone Area/Number Name of Parent/Guardian if minor Name/Addresses of Witnesses You may wish to attach signed statements. Type of incident Behavioral Accident Epidemic illness Other describe Date of Incident/Accident Hour Day of Week Month Day Year a*m* p*m* Describe the sequence of activity in detail including what the injured person was doing at the time Where occurred Specify location including location of injured and witnesses. Use diagram to locate persons/objects. Was injured participating in an activity at time of injury Any equipment involved in accident Yes No If so what activity What could the injured have done to prevent injury Emergency procedures followed at time of incident/accident By whom Submitted by Position Date Phone number Copyright 1983 by American Camping Association Inc* Revised 1990 1992 1999. Printed with permission of and under license of American Camping Association Inc* Medical Report of Accident Were parents notified Yes No By Writing Phone Other By whom T t e When il Time Date Parent s Response Where was treatment given check and complete all that apply At Accident Site Where By whom Treatment given Date Camp Health Service By whom T t e Released to Camp Activities Home Other Date Doctor s Office By whom T t e Hospital By whom T t e Was injured retained overnight in hospital Yes No If so which Out-patient In-patient Name of physician in attendance Date released from hospital Comments Camp Persons notified such as camp owner/sponsor board of directors etc* Name Position Describe any contact made with/by the media regarding this situation Signed Position Date Insurance Notification 1 Parent s Insurance 2 Camp Health Insurance 3 Worker s Compensation 4 Camp Liability Insurance By Parent Camp. Type of incident Behavioral Accident Epidemic illness Other describe Date of Incident/Accident Hour Day of Week Month Day Year a*m* p*m* Describe the sequence of activity in detail including what the injured person was doing at the time Where occurred Specify location including location of injured and witnesses. Use diagram to locate persons/objects. Was injured participating in an activity at time of injury Any equipment involved in accident Yes No If so what activity What could the injured have done to prevent injury Emergency procedures followed at time of incident/accident By whom Submitted by Position Date Phone number Copyright 1983 by American Camping Association Inc* Revised 1990 1992 1999. Use diagram to locate persons/objects. Was injured participating in an activity at time of injury Any equipment involved in accident Yes No If so what activity What could the injured have done to prevent injury Emergency procedures followed at time of incident/accident By whom Submitted by Position Date Phone number Copyright 1983 by American Camping Association Inc* Revised 1990 1992 1999. Printed with permission of and under license of American Camping Association Inc* Medical Report of Accident Were parents notified Yes No By Writing Phone Other By whom T t e When il Time Date Parent s Response Where was treatment given check and complete all that apply At Accident Site Where By whom Treatment given Date Camp Health Service By whom T t e Released to Camp Activities Home Other Date Doctor s Office By whom T t e Hospital By whom T t e Was injured retained overnight in hospital Yes No If so which Out-patient In-patient Name of physician in attendance Date released from hospital Comments Camp Persons notified such as camp owner/sponsor board of directors etc* Name Position Describe any contact made with/by the media regarding this situation Signed Position Date Insurance Notification 1 Parent s Insurance 2 Camp Health Insurance 3 Worker s Compensation 4 Camp Liability Insurance By Parent Camp.