Accident/Incident Report Form - American Camping Association

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Accident/Incident Report Form
FM 01
Developed by the American Camping Association
®
(Fill out 1 on each incident or person)
Camp Name
Date
______________________________________________________________________________________________________
____________________________________________________
Address
_______________________________________________________________________________________________________________________________________________________________________
Street & Number
City
State
Zip
Name of person involved
Age
Sex
Camper
Staff
Visitor
_________________________________________________
_____________
__________________
Last
First
Middle
Address
Phone
_______________________________________________________________________________________________________________________
______________________________________
Street & Number
City
State
Zip
Area/Number
Name of Parent/Guardian (if minor)
_______________________________________________________________________________________________________________________________
Address
Phone
_______________________________________________________________________________________________________________________
______________________________________
Street & Number
City
State
Zip
Area/Number
Name/Addresses of Witnesses (You may wish to attach signed statements.)
1.
_______________________________________________________________________________________________________________________________________________________________________________
2.
_______________________________________________________________________________________________________________________________________________________________________________
3.
_______________________________________________________________________________________________________________________________________________________________________________
Type of incident
Behavioral
Accident
Epidemic illness
Other (describe)
Date of Incident/Accident
Hour
a.m.
p.m.
______________________________________________________________________________
________________________
Day of Week
Month
Day
Year
Describe the sequence of activity in detail including what the (injured) person was doing at the time
________________________________
Where occurred? (Specify location, including location of injured and witnesses. Use diagram to locate persons/objects.)
Was injured participating in an activity at time of injury?
Yes
No If so, what activity?
________________________________________
Any equipment involved in accident?
Yes
No If so, what kind?
_______________________________________________________________________
What could the injured have done to prevent injury?
_______________________________________________________________________________________________________
Emergency procedures followed at time of incident/accident
__________________________________________________________________________________________
By whom?
____________________________________________________________________________________________________________________________________________________________________
Submitted by
Position
Date
__________________________________________________________________
_______________________________________
____________________________________
Phone number
_______________________________________________________________
Copyright 1983 by American Camping Association, Inc. Revised 1990, 1992, 1999.
Printed with permission of and under license of American Camping Association, Inc.
Accident/Incident Report Form
FM 01
Developed by the American Camping Association
®
(Fill out 1 on each incident or person)
Camp Name
Date
______________________________________________________________________________________________________
____________________________________________________
Address
_______________________________________________________________________________________________________________________________________________________________________
Street & Number
City
State
Zip
Name of person involved
Age
Sex
Camper
Staff
Visitor
_________________________________________________
_____________
__________________
Last
First
Middle
Address
Phone
_______________________________________________________________________________________________________________________
______________________________________
Street & Number
City
State
Zip
Area/Number
Name of Parent/Guardian (if minor)
_______________________________________________________________________________________________________________________________
Address
Phone
_______________________________________________________________________________________________________________________
______________________________________
Street & Number
City
State
Zip
Area/Number
Name/Addresses of Witnesses (You may wish to attach signed statements.)
1.
_______________________________________________________________________________________________________________________________________________________________________________
2.
_______________________________________________________________________________________________________________________________________________________________________________
3.
_______________________________________________________________________________________________________________________________________________________________________________
Type of incident
Behavioral
Accident
Epidemic illness
Other (describe)
Date of Incident/Accident
Hour
a.m.
p.m.
______________________________________________________________________________
________________________
Day of Week
Month
Day
Year
Describe the sequence of activity in detail including what the (injured) person was doing at the time
________________________________
Where occurred? (Specify location, including location of injured and witnesses. Use diagram to locate persons/objects.)
Was injured participating in an activity at time of injury?
Yes
No If so, what activity?
________________________________________
Any equipment involved in accident?
Yes
No If so, what kind?
_______________________________________________________________________
What could the injured have done to prevent injury?
_______________________________________________________________________________________________________
Emergency procedures followed at time of incident/accident
__________________________________________________________________________________________
By whom?
____________________________________________________________________________________________________________________________________________________________________
Submitted by
Position
Date
__________________________________________________________________
_______________________________________
____________________________________
Phone number
_______________________________________________________________
Copyright 1983 by American Camping Association, Inc. Revised 1990, 1992, 1999.
Printed with permission of and under license of American Camping Association, Inc.
Medical Report of Accident
Were parents notified?
Yes
No
By
Writing
Phone
Other
___________________________________________________________________
By whom?
Title
When
_________________________________________________________
_________________________________________________
__________________________________________
Time
Date
Parent’s Response
________________________________________________________________________________________________________________________________________________________
Where was treatment given (check and complete all that apply)?
At Accident Site: Where?
By whom?
_______________________________________________________
________________________________________________________________
Treatment given
Date
____________________________________________________________________________________________________________________
____________________________
Camp Health Service: By whom?
Title
____________________________________________________
________________________________________________________________
Treatment given
Date
____________________________________________________________________________________________________________________
____________________________
Released to
Camp Activities
Home
Other
Date
___________________________________________________________
____________________________
Doctor’s Office: By whom?
Title
_____________________________________________________________
________________________________________________________________
Treatment given
Date
____________________________________________________________________________________________________________________
____________________________
Released to
Camp Activities
Camp Health Service
Home
Other
_______________________________________________________
Hospital: By whom?
Title
_______________________________________________________________________
________________________________________________________________
Was injured retained overnight in hospital?
Yes
No
If so, which?
________________________________________________________________
Where?
Date
Out-patient
In-patient
________________________________________________________________
____________________________________________
Name of physician in attendance
______________________________________________________________________________________________________________________________
Date released from hospital
______________________________________________________________________________________________________________________________________
Released to
Camp
Home
Other
____________________________________________________________________________________________________________
Comments
___________________________________________________________________________________________________________________________________________________________________
Persons notified such as camp owner/sponsor, board of directors, etc.
Name
Position
Date
Describe any contact made with/by the media regarding this situation
____________________________________________________________________________
Signed
Position
Date
_________________________________________________________________________
_______________________________________
__________________________________
Insurance Notification
Date
1.
Parent’s Insurance
By
Parent
Camp
2.
Camp Health Insurance
3.
Worker’s Compensation
4.
Camp Liability Insurance

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