Form 680-016 Incident Information Report Form

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Incident Information Report
(Events or allegations of injury, illness, or property damage, including employment and issues with directors and officers)
Incident date: ___________________Time: __________________________
Reporting date: _________________Time: __________________________
Council/BSA location: ___________________________________________ ❏ Leader
❏ Parent
❏ Other: _____________________
Reporting person: ___________________________________________________________________________________________________
Location of incident: _________________________________________________________________________________________________
Specific area where incident occurred:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Cause of incident:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Program/event/adventure code: ______________________________________________________________________________________
Did the incident occur while transporting to/from an activity? ❑ Yes
❑ No
Comments:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Individuals Involved (Duplicate If Needed)
Name: ______________________________________________________________________________________________________________
First
Middle
Last
Address: ___________________________________________________________________________________________________________
City
State
Zip
Home phone: _______________________Cell phone: _________________________Work phone: ________________________________
DOB: _______________________________Age: _______Unit No.: _______________Council: ____________________________________
Scouting role: ______________________________________________________________________________________________________
Type of injury or property damage: ________________________Injured body part: ___________________________________________
Was medical treatment given at scene? ❑ Yes ❑ No
Type:____________________________________________________________
Medical disposition (transported to hospital, etc.): ______________________________________________________________________
Return this completed form to your council’s designated user for entry into RiskConsole via MyBSA Incident Entry.
Incident Information Report
(Events or allegations of injury, illness, or property damage, including employment and issues with directors and officers)
Incident date: ___________________Time: __________________________
Reporting date: _________________Time: __________________________
Council/BSA location: ___________________________________________ ❏ Leader
❏ Parent
❏ Other: _____________________
Reporting person: ___________________________________________________________________________________________________
Location of incident: _________________________________________________________________________________________________
Specific area where incident occurred:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Cause of incident:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Program/event/adventure code: ______________________________________________________________________________________
Did the incident occur while transporting to/from an activity? ❑ Yes
❑ No
Comments:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Individuals Involved (Duplicate If Needed)
Name: ______________________________________________________________________________________________________________
First
Middle
Last
Address: ___________________________________________________________________________________________________________
City
State
Zip
Home phone: _______________________Cell phone: _________________________Work phone: ________________________________
DOB: _______________________________Age: _______Unit No.: _______________Council: ____________________________________
Scouting role: ______________________________________________________________________________________________________
Type of injury or property damage: ________________________Injured body part: ___________________________________________
Was medical treatment given at scene? ❑ Yes ❑ No
Type:____________________________________________________________
Medical disposition (transported to hospital, etc.): ______________________________________________________________________
Return this completed form to your council’s designated user for entry into RiskConsole via MyBSA Incident Entry.
Incident Information Report
(Events or allegations of injury, illness, or property damage, including employment and issues with directors and officers)
Witnesses
Name: ______________________________________________________________________________________________________________
First
Middle
Last
Address: ___________________________________________________________________________________________________________
City
State
Zip
Home phone: _______________________Cell phone: _________________________Work phone: ________________________________
Others
Name: ______________________________________________________________________________________________________________
First
Middle
Last
Address: ___________________________________________________________________________________________________________
City
State
Zip
Home phone: _______________________Cell phone: _________________________Work phone: ________________________________
Property Damage (if applicable)
Property or vehicle make/model/year: _________________________________________________________________________________
Color: __________________________License plate No.: ___________________________________________________________________
Driver Contact Information (if applicable)
Name: ______________________________________________________________________________________________________________
First
Middle
Last
Address: ___________________________________________________________________________________________________________
City
State
Zip
Home phone: _______________________Cell phone: _________________________Work phone: ________________________________
Passengers: ________________________Contact information: _____________________________________________________________
Additional information:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Information gathered at scene by: ____________________________________________________________________________________
Contact information: _________________________________________________________________________________________________
Return this completed form to your council’s designated user for entry into RiskConsole via MyBSA Incident Entry.
680-016
2016 Printing

Download Form 680-016 Incident Information Report Form

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