Accident/Incident Form
Date of Report
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of person completing report:
*
First Name
Last Name
Phone Number of person completing report:
*
Email of person completing report:
*
Community Number:
Please Select
Select from the drop down
Community 2 Lake City
Community 3 Clay/Putnam
Community 4 Alachua
Community 5 St Johns/Flagler
Community 6 Duval
Community 7 Duval/Baker/Nassau
Community 9 Pensacola
Community 10 Panama City
Community 11 Tallahassee
GSGC Council Staff
Troop Number
*
Level
Please Select
Level
Daisy
Brownie
Junior
Cadette
Senior
Ambassador
Multi-Level
Adult
Date of Incident
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Incident
*
Hour Minutes
AM
PM
AM/PM Option
Location of Incident (Address, City, State, ZIP)
*
Injured Participant's Name
*
First Name
Last Name
Injured Participant's Age
*
Injured Participants' Parent's name (if minor)
*
First Name
Last Name
Injured Participant's Phone Number
*
Injured Participant's Email
*
Injured Participant's Address (Address,City, State, ZIP)
*
Relationship to GSGC
*
Girl
Volunteer
Member
Visitor
Delivery Personnel
Council Staff
Other
Type of Incident
*
Auto/Vehicles
Slips/Falls (on/at/over/from)
Using Tools
Aquatics (in/on water)
Poisonous Plants/Insects
Skating
Illness/sickness
Other
Incident Setting
*
Camp Outdoors
Camp Indoors
Parking Lot
Road/Highway
GSGC Property
Non-GSGC Building
Other
Describe the incident/injury, what occurred and subsequent resolution.
*
Please attach copies of any document or other supporting reports of the incident if applicable:
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Who was contacted? Check all that apply
Parents/Guardians
Emergency Services
None of the above
Hospital the injured participant was taken to, if applicable:
Was this incident a result of criminal activity?
*
Yes
No
Police report number, if applicable:
Was anyone else injured?
*
Yes (If yes, submit an additional form for each injured person)
No
Submit
Should be Empty: