8/7/2019 Appendix 9.8.4 - Accident & Incident Report Form

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Appendix 9.8.4 – Accident / Incident Report Form(This form is to be completed for all employee, patron and visitor accidents /incidents)

INSTRUCTIONS: All venue-related accidents/incidents (employee, patron, visitor, etc) require Sections I andII of this Accident/Incident Report to be completed by management or another employee of the venue. Theinjured person should not complete this report. Management is required to complete Section III on thereverse side, review the report for completeness and accuracy, sign and log this report in theaccident/incident log book within 24 hours of the accident/incident. Note: the report (and pictures if any)should then be filed together in a safe and secure location of the venue. Any copies of this report and anyother related materials in conjunction with this report cannot be obtained without the authorization of management.

SECTION I PLEASE PRINT OR TYPE ALL INFORMATION 

NAME: ___________________________________________________  _____________________________________  (Brief Physical Description)

HOME ADDRESS:

___________________________________________________________________________________________________Number/Street City State Zip

TELEPHONE NUMBER: ( )_____________________ AGE: ________ (required by insurance agency)

DATE OF BIRTH ______________ 

_____ EMPLOYEE _____ PATRON _____ VISITOR  (reason for being on premises)___________________________________ 

SECTION II ACCIDENT DATA

NATURE OF INCIDENT:____ Accident/Injury ____ Theft/Burglary____ Physical Altercation ____ Verbal Confrontation

____ Property Damage ____ Other  

DATE OF Accident /Incident: __________ TIME of Accident /Incident: _____________ ____AM ____PM

Accident /Incident occurred at: __Inside Venue__ Outside Venue __ Other Location (Specify Location) ________________________

Specific Location of Accident: __________________________________________________________________________________

  (Address / Vicinity / Actual Location)

Briefly explain what happened: (if an injury, (1) explain activities occurring when injury or illness occurred and what tools, machinery, chemicals, weapons,

were involved, (2) what happened to cause this injury or illness (3) what was the injury or illness (i.e., state the part of body affected and how it was affected) Useadditional paper if needed.

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

What action was taken: Check all actions taken. If more than one, indicate which occurred 1st, 2nd, etc.

_______  First Aid – administered by _____________________________________________ 

_______  Sent to Hospital/Physician (Name of Hospital/Physician) ____________________________________________________

_______  Pictures Taken (Number of Pictures Taken) _________________________________ 

_______ Sent Home

_______  Continued Activity (no action taken)

Venue Contact/Management: __________________  Name of Witness (if applicable) _______________  Phone: __________ 

Person Completing the Report _________________________________________________________ Date: ____________ 

Reviewed by Venue Owner/Risk Manager _____________________________________________  Date: ____________ 

Return form same day (or within 24 hours) of accidents/incident for employee, patron, or visitor

the corresponding Risk Owner, or Dr. Lipsett.

8/7/2019 Appendix 9.8.4 - Accident & Incident Report Form

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Accident/Incident Report Form page 2

SECTION III MANAGEMENT/SUPERVISOR REPORT ON THE ACCIDENT/INCIDENT 

What action has been taken to prevent such an accident/incident from recurring? Include specific details on how it was

mediated, how the incident can be avoided in the future. (Note that photos are highly recommended immediately following an

incident, if at all possible.)

____________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Management/Supervisor’s Account of Incident which supplements and/or clarifies information provided by injured party: (if an

injury, (1) explain activities occurring when injury or illness occurred and what tools, machinery, chemicals, were involved, (2) what happened to cause this injury or 

illness (3) what was the injury or illness (i.e., state the part of body affected and how it was affected)

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Section III Completed by: ____________________________________________ ___________________ 

Signature Date

SECTION IV- FOR INVESTIGATION/REVIEW ONLY - DO NOT WRITE BELOW THIS LINE:

Investigation Comments: Photos are highly recommended immediately following an incident, if at all possible.

Required Action:

Location Code: ____ 

Section IV Completed by: ____________________________________________ ___________________ 

Signature DateDate sent to management: ________________ other ___________________________ 

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