INCIDENT REPORT Name of Member * Age? * Date of Injury * MM DD YYYY Time of Injury? * Hour Minute Second AM PM Parent/Guardian Name: * Phone * (###) ### #### Description of Injury * Specific activity/program involved in at time of injury: * Was any medical attention needed? * Yes No If yes, describe care given: Describe fully, which part of the body was injured. Was participant transported to the hospital? * Yes No If yes, which hospital? Was parent/guardian notified? * Yes No Additional notes: Name of Employee * First Name Last Name Injury Report Submitted