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

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