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:

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

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

3. Name of Person 1 involved:

4. Person 1 age:

5. Person 1 address (if known):

6. Person 1 phone:

7. Name of Person 2 involved:

8. Person 2 age:

9. Person 2 address (if known):

10. Person 2 phone:

11. Information on other people involved:

12. Date accident/ incident occurred

13. Please indicate the type of incident which occurred:

14. Was someone injured?

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

16. Please indicate the type of life threatening emergency:

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

18. Description of accident/ incident:

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

20. Was a MACRD staff member notified?

21. If yes, who?

22. Were Emergency Personnel called?

23. If yes, who came to the scene?

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

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

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