Incident Report Form
Use this form if an incident or accident occurred to Girl Scout member during a Girl Scout activity. Fill out 1 on each incident or person.
First Name of Person Involved
Name of Caregiver if person involved is a minor
Full Address of Person Involved/Caregiver
Relationship to GSSNV
Address of witness/reporter
First Name of second witness
Last Name of second witness
Upload any signed statements you wish to attach here
Type of Incident
If Other, please specify
Date of Incident
Time of Incident
Incident Location Phone Number
Was the person involved injured?
If the person involved was injured, were they participating in an activity at the time of the injury?
If yes, what activity?
Was any equipment involved in the incident?
If yes, what kind of equipment?
Emergency procedures followed at the time of the incident, if applicable
Name of Person Submitting
Position of Person Submitting
Contact Number of Person Submitting
Send me a copy of my responses
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