Incident Report Form
What was the condition of the injured/ill party, when you arrived on the scene?
:
Was First Aid administered?
Yes
No
If yes, who administered it?:
Was more than First Aid required?
Yes
No
If yes, describe
:
Was professional medical attention declined?:
Yes
No
If yes, who declined it?:
Describe Medical attention:
Ambulance #:
Was injured/ill party taken to the Hospital?:
Yes
No
If yes, Name & Address of Hospital:
If the injured/ill party left on their own, did they say they will see a doctor?:
Yes
No
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?
:
Yes
No
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