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Recreation 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
*
M
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
*
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?
Yes
No
EMERGENCY MEDICAL SERVICES
Was EMS called?
*
Yes
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?
*
Yes
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 301-600-1684 with any questions.
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