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Incident Report – East Gate
Please complete all of the following information as it pertains to this incident. Remember, on a form such as this, more info is always better than less.
Date of Incident
*
Time of Incident
*
:
HH
MM
AM
PM
Location of Incident
Incident Description
Additional Facts
IINJURED PARTY INFORMATION (Complete a separate report for each injured party)
Injured Party
*
Club member
Guest
Employee
Other
Name
Age
Address (required for non-members)
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone #
Injury Description
Was additional assistance requested?
No
EMS
Fire
Police
Physician
Did injured party refuse first aid or medical assistance?
No
Yes
Was injured party transported to hospital? If so, which hospital and by whom (EMS or Person)?
WITNESS INFORMATION
Witness Name
First
Last
Witness Statement
Witness Phone
Staff on Duty
Report Completed By
First
Last
Email
*
Additional Comments
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