Services
Facility Risk Assessments
Staff Training
Emergency Plans
Expert Services
Resources
Case Study 1
Case Study 2
Resources
About
Contact
JOIN
Log In
Incident Report Form
INCIDENT REPORT
EAP: Incident Report
Admin Use Only
FACILITY INFORMATION
Today’s Date
*
Organization Name
*
Venue Name
*
Address
*
Address
Address
Address
City
City
State
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip
Zip
Type of Incident
*
Medical Emergency
Patron Conduct
Both
INCIDENT INFORMATION
Date of Incident
*
Time of Incident
*
12
1
2
3
4
5
6
7
8
9
10
11
:
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM
PM
Name of Person Involved in Incident
*
Name of Person Involved in Incident
First
First
Last
Last
Address
Address
Address
Address
City
City
State
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip
Zip
Phone of Person Involved
Email of Person Involved
How is the injured person associated with your organization?
*
Member
Guest
Participant
Spectator
Sponsor/Donor
Unsure
Membership #
*
Upload a copy of the Membership/Rental Agreement/Waiver
Drop a file here or click to upload
Choose File
Maximum file size: 516MB
Gender
Male
Female
Other
Is the person involved a minor?
*
Yes
No
Location of the Incident
*
Incident Took Place During
*
Normal Hours of Operation
Game/Event
Practice
Rental Event
Other
Type of Injury
*
Abrasion
Allergic Reaction
Bruise
Burn
Cardiac Arrest
Concussion
Cut (Laceration)
Death
Electric Shock
Fall/Tripped
Fracture
Heat Illness
Nausea/Vomiting
Seizure
Sting/Bite
Stroke
Other
Other
Injured Body Part (check all that apply)
*
Ankle (R)
Ankle (L)
Arm (R)
Arm (L)
Back
Chest
Chin
Collar Bone (Clavicle)
Ear (R)
Ear (L)
Elbow (R)
Elbow (L)
Eye (R)
Eye (L)
Face
Finger(s)
Foot (R)
Foot (L)
Hand (R)
Hand (L)
Head
Heel (R)
Heel (L)
Knee (R)
Knee (L)
Lips
Neck
Nose
Ribs
Shin (R)
Shin (L)
Shoulder (R)
Shoulder (L)
Stomach
Teeth
Thigh (R)
Thigh (L)
Toe(s)
Wrist (R)
Wrist (L)
Other
Other
NO INJURIES
MEDICAL PROCEDURES TAKEN BY STAFF
Was CPR performed by a staff member?
*
Yes
No
Was an AED used?
*
Yes
No
Was First-aid administered by a staff member?
*
Yes
No
Was there Blood present?
*
Yes
No
Did the injured person lose conciousness?
*
Yes
No
Was an ambulance called?
*
Yes
No
Was the person transported to the hospital?
*
Yes
No
Did the person refuse medical help?
*
Yes
No
Did anyone view the incident happen?
*
Yes
No
If yes, have that person fill out a witness report.
Names of Witnesses
PATRON CONDUCT INFORMATION
Type of Incident involving patron?
*
Behavioral Issue
Drunk & Disorderly
Equipment Abuse
Failure to Follow Facility Rules
Fight/Altercation
Inappropriate Sign
Throwing Objects
Use of Foul Language
Other
Other
Check all that apply.
Was a Police Officer called to the scene?
*
Yes
No
What action was taken?
*
Arrested
Escorted Out of Facility
Verbal Warning Issued
If person was arrested, did you get a copy of the police report?
*
Yes
No
Not Applicable
DESCRIPTION OF THE INCIDENT
Describe the incident with as much detail as possible.
*
0
of 500 max words
Please state only the facts. Do not give your opinion on what you think caused the incident.
PHOTOS/VIDEOS
Upload any photos and/or videos of the incident here:
Drop a file here or click to upload
Choose File
Maximum file size: 516MB
REPORT COMPLETED BY:
Name
*
Name
First
First
Last
Last
Staff Member Phone
Do you want to send a copy of this report to your insurance carrier today?
*
Yes
No
INSURANCE INFORMATION
Fill out this section if you need to file a claim with your insurance carrier.
Organization’s Insurance Carrier Name
Organization’s Insurance Policy #
Organization’s Insurance Carrier Email
Leave blank if you don’t want to send a copy to the insurance company.
Email Contacts
Organization Email
*
Click “Add” to send this form to other email recipients.
plus1
Add
minus1
Remove
Submit
If you are human, leave this field blank.
Δ
Emergency Forms
