Girl Scouts of Western Ohio | Incident/Accident Report Form

SUBMIT WITHIN 24 HOURS AFTER ACCIDENT/INCIDENT -

THIS IS NOT A CLAIM

Name of Injured Person

Age

Address

City

State

Zip

Home Phone

Please enter a valid phone number with format (xxx)xxx-xxxx

Second Phone

Please enter a valid phone number with format (xxx)xxx-xxxx

Troop #

Paid Staff Position

Name of Parent/Guardian if minor

Address

City

State

Zip

PART I: Incident/Accident Information

Date of Incident/accident

MM/DD/YY

Time of incident/accident

Incident/Accident Location

City

State

Incident Location Zip

Description of Incident

Injury/Illness Location & Site

Body Part

If so, what activity?

If so, what kind?

PART II: Witnesses

Name

[+]

Phone

[+]

Please enter a valid phone number with format (xxx)xxx-xxxx

Address

[+]

PART III: Treatment Summary

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

Where

By whom

Date

MM/DD/YY

Diagnosis

If hospitalized, name of hospital

Date of hospitalization

MM/DD/YY

Treatment given/diagnosis

PART IV: If Vehicle(s) Involved, Complete the Following

Driver of Vehicle Used for Girl Scout Activity:

Name

Phone

Address

Driver's License #

State of

Vehicle registration #

License plate #

Insurance

Driver of second vehicle:

Name

Phone

Address

Driver's License #

State of

Vehicle registration #

License plate #

Insurance

Report issued by

PART V: Person Completing This Report

Name

Phone

Please enter a valid phone number with format (xxx)xxx-xxxx

Signature

Date

MM/DD/YY

Time