ACCIDENT REPORT FORM

(fill in all spaces)

Person Injured Phone No.

(Street No.) (City) (State) (Zip)

Date of Injury Time of Injury

Site of Accident

Type and extent of injuries based on . . .

1) Immediate first aid observations

2) Treatment by medical personnel

Was the immediate family notified? Yes No

By whom? Time

Whose or what insurance will pay?

Their plans and comments

Who from Scouting will follow up?

Who was the first person on the scene and their actions?

Name Action taken

Other persons on the scene and their actions taken

Cover these seven (7) points:

1) List sequence of the activity

2) Exactly what was the injured person doing and how did the accident occur?

3) Location of accident on property. Please draw diagram of exact location and what they were doing

Please draw simple diagram here.

4) Was there any damage to property? If so, whose property and what damage was done?

5) Ask the injured party what happened and what they were doing? Write down any admissions by the injured person that he was not following directions or did something wrong, or failed to do something he was supposed to do.

6) First aid procedure rendered?

Which emergency service was called?

Which medical facility was the injured party taken to?

7) Any unique circumstances (ie., weather)?

Do not put down what was not done, only what was done.

Do not give your opinion on this form – keep it factual.

Attach eye witness reports. (staple)

Death or very serious injured must have a call placed to the Scout Executive. (507) 287-1410, or (800) 524-3907.

This report must be submitted within three (3) days of accident to the Scout Executive. Accidents which may lead to a liability claim must be reported promptly.

Insurance report form was given to Date

(Signed)

Date)