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Incident/Accident Report Form

SUBMIT WITHIN 24 HOURS AFTER ACCIDENT/INCIDENT -
THIS IS NOT A CLAIM
 
 
 
 
 
 
 
Please enter a valid phone number with format (xxx)xxx-xxxx
 
Please enter a valid phone number with format (xxx)xxx-xxxx
 
 
 
 
 
 
 
PART I: Incident/Accident Information
 
MM/DD/YY
 
 
 
 
 
 
 
 
 
 
PART II: Witnesses
 
[+]
 
[+]
Please enter a valid phone number with format (xxx)xxx-xxxx
 
[+]
PART III: Treatment Summary

If treatment was given by first aider, doctor or emergency medical facility, describe below:

 
 
 
MM/DD/YY
 
 
 
MM/DD/YY
 
PART IV: If Vehicle(s) Involved, Complete the Following
 

Driver of  Vehicle Used for Girl Scout Activity:

 
 
 
 
 
 
 
 

Driver of second vehicle:

 
 
 
 
 
 
 
 
 
PART V: Person Completing This Report
 
 
Please enter a valid phone number with format (xxx)xxx-xxxx
 
 
MM/DD/YY
 
*