Required fields are marked with asterisks (*)

Recreation and Parks Services Division - Incident Report

Section A: Individual

Enter individual's information. If the individual is age 16 or younger, insert parent or guardian's name and contact information in addition to child's information.

First Name

Last Name

Date of Birth

Address

Apt/Unit #

City

Province

Postal Code

Phone Number

Is the individual age 16 or younger?

Yes

Section B: Responder

Enter responder information and the name of the person filling in this report.

Report filled out by:

Responding staff member:

Date of Incident

Time of Incident

Location of Incident

Responding Staff Department

Responding Staff Supervisor

Section C: Incident

Enter details about the incident. Be as specific as possible.

Did anyone witness the incident?

Yes

Section D: Medical

Level of Awareness

Conscious

Semiconscious

Unconscious/Non-responsive

Airway

Open

Partially obstructed

Obstructed

Breathing

Normal

Labored/trouble breathing

Not breathing

General Assessment

Bleeding

Skin is cold, clammy, or discolored

Possible broken bone

Suspected concussion

Pulse not present/not detectable

Additional notes:

Section E: Emergency Services

Enter details about the incident. Be as specific as possible.

Action taken

No action required

First Aid administered

CPR administered

Defibrillator used

Was 911 contacted?

Yes

Section F: Report Acknowledgement

By submitting this report, you are certifying that the information contained within is correct to the best of your knowledge, are you agree that if further information becomes available you will report this information to your supervisor. The information contained within this report is of a confidential nature and should only be shared with the area coordinator, building in-charge, and/or management.

Responding Staff:

Date of incident:

Incident Report submitted by:

Email Address

Date of entry: