Girl Scouts of NENY Accident Report
To be completed for any reported serious accident involving substantial medical care and/or potential major insurance claim.
Name of Injured
First Name
Last Name
If child, age:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Parent/Guardian (if child)
First Name
Last Name
Date of Accident
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date Reported
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Accident
Describe Exact Location of Accident (name of camp, recreation, business, or other facility, specifically what type of facility, etc.)
If Accident occurred outside, describe the specific conditions (rain, snow, ice, wet, dry, warm, cold, sun, clouds, etc.)
Please list names of any other persons involved in accident and whether they had injuries.
Please describe the nature of the injury.
What medical attention was sought or obtained and how quickly was it summoned? (rescue squad, paramedics, taken to hospital, by whom? etc.)
Please describe clearly how the accident happened.
In your opinion, what was the immediate cause of the accident (what action or failure to act and/or conditions contributed most directly?)
Witness 1
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Witness 2
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are any of these witnesses related to the injured? If so, who and what is the relationship?
Name of Person completing this form
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
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