Safety Incident/Injury Report

Please fill out this form factually, to the best of your ability and memory, if you observed an injury or an incident occured at Technocopia. Your information will help us correctly address the situation and develop better policies and procedures to make our community even safer.

Name *

Name

Name of person involved in incident/injury.

First Name

Last Name

Parent/Guardian

If involved person is a minor, please include name of parent/guardian.

First Name

Last Name

Member

Staff/Voluenteer

Student

Other

Age

Age of the involved person.

Sex

Male

Female

Phone Number

Contact information of involved person, so we can follow up on the incident.

Date of Incident/Injury *

Date of Incident/Injury

MM

DD

YYYY

Time of Incident/Injury *

Time of Incident/Injury

Hour

Minute

Second

Events leading up to the Incident *

What was the injured doing before the incident?

Events involved in the Incident *

What happened to the injured?

Was equipment involved?

Events Immediately following the Incident *

What happened after the injury occured?

Specific Injuries *

Parts of body injured & nature of injuries.

Treatment of injuries *

Specific treatments administered to injuries.

Additional Information

Please include any additional relevant information

Name of Individual Filling out Report *

Name of Individual Filling out Report

First Name

Last Name

Your Number *

We may want to contact you for additional information. Thank you!