Accident/ Incident Report Tracking Survey

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* 2. Name, phone number, and email of person reporting the accident/incident:

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* 3. Name of Person 1 involved:

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* 4. Person 1 age:

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* 5. Person 1 address (if known):

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* 6. Person 1 phone:

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* 7. Name of Person 2 involved:

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* 8. Person 2 age:

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* 9. Person 2 address (if known):

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* 10. Person 2 phone:

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* 11. Information on other people involved:

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* 12. Date accident/ incident occurred

Date / Time

Date

Time

AM/PM

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* 13. Please indicate the type of incident which occurred:

Physical altercation

Verbal altercation

Theft

Bullying/ Harassment/ Discrimination/ or similar

Vandalism - Damage to MACRD property

Vandalism - Damage to personal property

Vandalism - Damage to facility

Life threatening emergency/ injury/ accident

Non-life threatening emergency/ injury/ accident

Other (please specify)

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* 14. Was someone injured?

Yes

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* 15. If victim was a minor, did parent/ guardian consent to treatment?

Yes

Not applicable

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* 16. Please indicate the type of life threatening emergency:

Breathing emergency

Cardiac emergency

Seizure

Severe bleeding

Unresponsiveness

Not applicable (non-life threatening emergency)

Other (please specify)

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* 17. Please indicate type of non-life threatening emergency:

Sudden illness

Injury to muscle, bone, or joint

Spinal injury/ concussion

Minor bleeding

Water rescue

Not applicable

Other (please specify)

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* 18. Description of accident/ incident:

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* 19. Witness information (please list name(s) and phone number(s)):

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* 20. Was a MACRD staff member notified?

Yes

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* 21. If yes, who?

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* 22. Were Emergency Personnel called?

Yes

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* 23. If yes, who came to the scene?

Madras PD

Madras Fire/ EMS

Jefferson County Sherriff

No one was called to the scene

Other (please specify)

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* 24. For injuries, please indicate how the person was released:

Returned to activity/ report only

Released to personal vehicle

Transported by EMS

Released to law enforcement

Released to parent (if minor)

Not applicable

Accident/ Incident Report Tracking

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* 1. Please select the facility/ location where this incident occurred:

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* 2. Name, phone number, and email of person reporting the accident/incident:

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* 3. Name of Person 1 involved:

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* 4. Person 1 age:

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* 5. Person 1 address (if known):

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* 6. Person 1 phone:

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* 7. Name of Person 2 involved:

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* 8. Person 2 age:

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* 9. Person 2 address (if known):

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* 10. Person 2 phone:

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* 11. Information on other people involved:

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* 12. Date accident/ incident occurred

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* 13. Please indicate the type of incident which occurred:

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* 14. Was someone injured?

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* 15. If victim was a minor, did parent/ guardian consent to treatment?

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* 16. Please indicate the type of life threatening emergency:

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* 17. Please indicate type of non-life threatening emergency:

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* 18. Description of accident/ incident:

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* 19. Witness information (please list name(s) and phone number(s)):

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* 20. Was a MACRD staff member notified?

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* 21. If yes, who?

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* 22. Were Emergency Personnel called?

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* 23. If yes, who came to the scene?

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* 24. For injuries, please indicate how the person was released:

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* 25. If transported to hospital, please indicate which hospital or care facility:

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* 26. Please add additional comments or follow up information below: