Incident Report Form

Use this form if an incident or accident occurred to a Girl Scout member during a Girl Scout activity. Fill out 1 form for each incident or person.

Today's Date*

Person Involved

First Name of Person Involved

Name of Caregiver if person involved is a minor

Full Address of Person Involved/Caregiver

Age

Gender

Relationship to GSSNV

Camper/Member

Staff

Volunteer

Visitor

Witnesses

Address of witness/reporter

First Name of second witness

Last Name of second witness

File Attachments

Upload any signed statements you wish to attach here

Drag and drop files here or

Incident Details

Type of Incident

Behavioral

Accident

Illness

Other (describe)

If Other, please specify

Date of Incident

Time of Incident

Incident Location

Incident Address

Incident Location Phone Number

Incident Description

Was the person involved injured?

Yes

No

If the person involved was injured, were they participating in an activity at the time of the injury?

Yes

No

If yes, what activity?

Was any equipment involved in the incident?

Select

If yes, what kind of equipment?

Emergency procedures followed at the time of the incident, if applicable

By whom?

Submission Details

Name of Person Submitting

Position of Person Submitting

Contact Number of Person Submitting

Send me a copy of my responses

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