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Frederick County Recreation Council Accident Report

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This form has been modified since it was saved. Please review all fields before submitting.

Name of Injured*
Age*
Gender*
1. M
2. F
Street Address*
City*
State*
Zip*
Phone Number*
Place the Injury Occurred:*
Date and Time of Injury*
Date and Time of Injury
Date and Time of Injury
Person Reporting Injury*
Phone Number*
Name of Recreation Council*
How did the accident occur? Ask the injured person to explain in his or her own words:*
Describe the injury: *
Explain the first aid that was given:
Who administered First Aid?
Is this person currently certified in First Aid and CPR?
1. Yes
1. No
EMERGENCY MEDICAL SERVICES
Was EMS called? *
1. Yes
2. No (skip down to Notify Family)
Time Called (If applicable)
Time Called (If applicable)
Time of Arrival (if applicable)
Time of Arrival (if applicable)
Services rendered by EMS:
NOTIFY FAMILY
Was a Family Member Notified?*
1. Yes
2. No (skip down to Witnesses)
Time the Family Member was Notified:
Time the Family Member was Notified:
Method of Notifying Family Member:
Who was the Family Member Notified?
Relationship to Injured
WITNESSES
Please give names and phone numbers of two witnesses
Name of Witness #1*
Phone Number of Witness #1*
Name of Witness #2
Phone Number of Witness #2
Name of person completing this report:
Date:
Date:
Address1
City
State
Zip
Phone Number
Please call 301-600-1649 with any questions.