Fill and Sign the Haven University Transcript Form

Incident/ Accident Report Name of person involved: Address: City: State: Phone:( ) rGirl - Troop Number: Zip: Age: Sex: rStaff rVolunteer rOther Name of Parent/Guardian (if minor): Address: City: State: Zip: Date of Incident (XX/XX/XXXX): Time: rA.M. r P.M. Name of facility where incident/accident took place: Name and address of witness(s). (You may wish to attach signed statements.) 1. Witness Name: Address: City: State: Zip: City: State: Zip: City: State: Zip: 2. Witness Name: Address: 3. Witness Name: Address: Type of incident: rBehavioral rAccident rOther (describe): rIllness List any injuries: Describe the sequence of activity in detail including what the person was doing at the time of the incident/accident: Where did the incident/accident occur? (specific location – draw diagram to show location of persons/objects): Was individual participating in an activity at time of the incident/accident? rYes rNo If yes, what activity? Any equipment involved in incident/accident? rYes rNo If yes, what type? Condition of equipment: Emergency procedures followed at time of incident/accident: By whom: Report submitted by: Position: Phone:( Address: City: Date: ) State: Zip: over  7/10 Medical Report of Accident How much time lapsed between injury and First Aid? Were parents notified? rYes rNo By: r Writing rPhone rOther: By whom: Title: Date of Notification: Time of Notification: rA.M. r P.M. Parent’s response: Where was treatment given? rAt Accident Site rDoctor’s Office rHospital By whom: Date of Treatment: Time of Notification: rA.M. rP.M. Describe treatment given: Was injured person admitted overnight in a hospital? rYes rNo If so, what Time: rA.M. rP.M. Name of hospital: If hospitalized, how was injured person transported? rCouncil Vehicle rVolunteer Vehicle rAmbulance Attending physician’s name: Date released from hospital: Released to: rVolunteers Time released from hospital: rParents rA.M. rP.M. rOther: Comments about incident/accident: Persons notified such as Girl Scout Executive Director, staff member, etc.: Name Date Position If applicable, describe any comments to the media regarding this situation and by whom: Signature of Person Submitting This Report: For Council Use Only: Insurance Notification: By Whom: Date: 1. r Worker’s Compensation 2. rGeneral Liability Insurance 3. rAutomobile Insurance 4. rUnited of Omaha 5. rOther: NOTE: Any documentation, etc. should be initialed, dated and attached to this form 7/10