Girl Scout Council of the Mid-South - Accident Incident Report

Girl Scout Council of the Mid-South


	Accident/Incident Report

File this report within 24 hours of an accident/incident that occurs during a Girl Scout activity.

Fields marked with an asterisk are required.*

Person Involved/ Injured
First Name:*
Last Name:*
Home Phone:*
Work Phone:
Cell Phone:
Address:*
City:*
State:*
Zip:*
Troop #:*
Age Level:*	D Br Jr Teen Girl Scout 11-17
Classification:*	Adult / Girl
Age / Sex:*	Male / Female
Parent/Guardian (if minor), First Name:*
Parent/Guardian (if minor), Last Name:*
Parent/Guardian Home Phone:*
Parent/Guardian Work Phone:
Was Parent Notified:*	Yes / No
If so, by whom:

Description of Accident/Incident
Date:*	(mm/dd/yy)
Time:*	(include am or pm)
Location:*
Type of Activity:*
Describe what happened and injury:*

Witnesses
First Name (Witness #1):
Last Name (Witness #1):
Phone:
Address:
City:
State:
Zip:
First Name (Witness #2):
Last Name (Witness #2):
Phone:
Address:
City:
State:
Zip:

Describe Care Given
Care given by whom, First name:*
Care given by whom, Last name:*
Describe Care Given:*

Medical Treatment
Physician's First name:
Physician's Last name:
Location:
Hospital:
Location:
Was person retained overnight in hospital?:	Yes / No
If so, date released:	(mm/dd/yy)

Person Completing This Form
First Name:*
Last Name:*
Phone:*
Email:
Address:*
City:*
State:*
Zip:*
Girl Scout Position:*
Signature:*	(Typing your name here qualifies as a valid signature)
Date:*	(mm/dd/yy)

You may submit form electronically by clicking submit or print and deliver to the
Girl Scout Council of the Mid-South
Mail: PO Box 240246, Memphis, TN 38124-0246
Deliver: 2715 Kirby Parkway, Suite 1
Fax: (901) 797-2183