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What was the condition of the injured/ill party, when you arrived on the scene?
Was First Aid administered?
If yes, who administered it?:
Was more than First Aid required?
If yes, describe
Was professional medical attention declined?:
If yes, who declined it?:
Describe Medical attention:
Was injured/ill party taken to the Hospital?:
If yes, Name & Address of Hospital:
If the injured/ill party left on their own, did they say they will see a doctor?:
If Yes, Name & Address of Physician:
What was the condition of the injured/ill person when they left your premises?:
Did the injury occur in connection with the operation of an amusement ride or inflatable?
If yes, which ride/inflatable was involved?:
To whom was the injury reported?:
What company personnel did you notify?:
When and how did you make this notification
Attach any photos of the injury
Attach any relative documents