SLAG Incident Report Form

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:

Month Day Year Hour Minutes AM/PM Option

Date and time when incident occurred:

Month Day Year Hour Minutes AM/PM Option

Incident report issued by (YOUR NAME)

First Name Last Name

YOUR E-mail

YOUR Phone Number

Area Code Phone Number

Did you call 911?

yes no

If yes, what time?

Did the police come?

Yes NO

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 Name Last Name

Involvement of person involved in incident / accident

Participant in SLAG program Volunteer Staff Skate park user

Phone Number

Area Code Phone Number

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Further Comments / Witness information & contacts / etc

*

I certify that the above information is true and correct.

Reporter Signature

Clear

Skate Like a Girl Incident Report