Name of affected person *

First Name

Last Name

Gender of affected person

Female

Male

Date of incident

MM

DD

YYYY

Time of incident

Hour

Minute

Second

AM PM

Type of incident

Minor Injury

Major Injury

Missing person

Rescue

Harassment or Abuse

Other

Name of Staff (1):

Name signed acts as electronic signature.

First Name

Last Name

Date Signed:

MM

DD

YYYY

I have read and approve all details on this incident report.

Yes

Name of Staff (2):

Name signed acts as electronic signature.

First Name

Last Name

Date Signed:

MM

DD

YYYY

I have read and approve all details on this incident report.

Yes