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INCIDENT, ACCIDENT, ILLNES, DEATH OR ARREST REPORT
INCIDENT, ACCIDENT, ILLNES, DEATH OR ARREST REPORT
Name Of Participant
Name Of Participant
(Required)
First
Last
Date & Time Of Incident
Date Of Incident
(Required)
MM slash DD slash YYYY
Time
(Required)
:
Hours
Minutes
AM
PM
AM/PM
Incident Location & Info
Location Of Incident
(Required)
Explained What Happened
(Required)
Injuries
Was There An Injury
(Required)
Yes
No
Physician/Medical Facility
Date Care Given
MM slash DD slash YYYY
Time Care Given
:
Hours
Minutes
AM
PM
AM/PM
Diagnosis & Treatment
Corrective action taken by staff to remedy and/or prevent recurrence
Names of persons notified
Friendship Circle Director
Physician or nurse
Parent or legal guardian of child
Law enforcement Agency
Additional Notes
Name and Signature of person completing report
Name Of Person Completing Report
(Required)
First
Last
Title Of Person Completing Report
Email Of Person Completing Report
(Required)
Phone Number Of Completing Report
(Required)
Signature Of Person Completing Report
(Required)
Date Report Completed
MM slash DD slash YYYY
Time Report Completed
:
Hours
Minutes
AM
PM
AM/PM
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