ACCIDENT/INCIDENT
REPORT FORM
To be completed by Walk
Leader
Date of
incident: ______________________ Time: _____________________
Name of
injured person: ___________________________________________________
Address: _______________________________________________________________
___________________________________________________________________________
Phone
number: _________________________________________________________
Date of
birth: _______________________________________________________________
Type of
injury: _______________________________________________________________
Details of
incident: _________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Medical
treatment required: Yes/No___________________
Name of
doctor/hospital: ___________________________________________________
Treatment: _______________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
*No medical
attention was desired/required by injured person –
agreed by
___________________________________________________________________________
Name of Walk
Leader: _______________________________
Date: _______________
This form to be
returned to Secretary by Walk Leader
August 2016 EARC
Accident/Incident Form