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Get Scouts Canada Incident Report Form

REVISED OCTOBER 2003 Appendix G Scouts Canada Incident Report Form Report any incident which might lead to a claim against Scouts Canada by 1. Follow up by immediately completing and submitting an Incident Report Form to Scouts Canada 1345 Baseline Road Ottawa ON K2C 0A7 preferably by FAX to 613-224-3571. Immediately following the incident call Scouts Canada at 1-800-339-6643 and select the menu option instructing you to report an incident which might lead to a claim* 2. Failure to notify may result in loss of insurance coverages. PLEASE PRINT INFORMATION ON THE GROUP Group Name Section Name Address Phone numbers Home Work Fax E-mail 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 Witness Name Home Phone Work Phone COMPLETE ONLY IF THIS INCIDENT WAS REPORTED TO POLICE Police Station Name/Number Name and Phone Number of Officer in Charge Page 1 of 2 February 2003 Birth date Complete this section if this person is a registered member. Please describe nature of injury or property damage Group Complete if applicable Name of doctor consulted Name and address of hospital or clinic Youth member or Adult member Please circle one Telephone REPORTING DETAILS This report must be signed by a currently registered Scouting member or a current employee of Scouts Canada* Family Name Given Name Position in Scouting City Province Postal Code Signature A copy of this report should also be sent to your local Council Office. Street Date If a vehicle was involved print name address and telephone number of vehicle owner and vehicle driver if not the same on a separate sheet of paper. If this report includes a claim for dental services attach a Standard Dental Claim Form which is available from your dentist. Submission of this report will only constitute an indemnity insurance claim if receipts are attached* For National Office use only REPORT NO. Failure to notify may result in loss of insurance coverages. PLEASE PRINT INFORMATION ON THE GROUP Group Name Section Name Address Phone numbers Home Work Fax E-mail 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 Witness Name Home Phone Work Phone COMPLETE ONLY IF THIS INCIDENT WAS REPORTED TO POLICE Police Station Name/Number Name and Phone Number of Officer in Charge Page 1 of 2 February 2003 Birth date Complete this section if this person is a registered member. Please describe nature of injury or property damage Group Complete if applicable Name of doctor consulted Name and address of hospital or clinic Youth member or Adult member Please circle one Telephone REPORTING DETAILS This report must be signed by a currently registered Scouting member or a current employee of Scouts Canada* Family Name Given Name Position in Scouting City Province Postal Code Signature A copy of this report should also be sent to your local Council Office.

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