SLAG Incident Report Form

Skate Like a Girl Incident Report
Report and submit within 24 hours. For head injuries or anything involving law inforcement, notify Risk Manager immediately at 425 802 2185.

You can find the Incident Response & Reporting guidelines HERE.
Chapter*
Report date and time:

MonthDayYearHourMinutesAM/PM Option
Date and time when incident occurred:

MonthDayYearHourMinutesAM/PM Option
Incident report issued by (YOUR NAME)

First NameLast Name
YOUR E-mail
YOUR Phone Number

Area CodePhone Number
Did you call 911?

yesno
If yes, what time?
Did the police come?

YesNO
If yes to above, what is the Case Number
Incident Location (Please provide specific details):
Describe Incident: what happened, how it happened, factors leading to the event, substances or objects involved. Be as specific as possible
Describe any specific injuries: Was the individual injured? If so, describe the injury (laceration, sprain, etc.), the part of body injured and any other information known about the resulting injury(s)
What action was taken? Was medical treatment provided? Y / N / Refused Were parents notified? Y / N Describe action taken
Information About the Person Involved in the Incident / Accident

First NameLast Name
Involvement of person involved in incident / accident

Participant in SLAG programVolunteerStaffSkate park userOther
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Further Comments / Witness information & contacts / etc
*

I certify that the above information is true and correct.
Reporter Signature

Clear
Should be Empty:

Skate Like a Girl Incident Report