BCASI incident report form:
Name of Person Injured: __________________________ Phone #_________________
Date of Incident: __________________ Time: _________________________________
Location of Incident: _____________________________________________________
Name of Instructor in attendance: ___________________________________________
Nature of Incident: Minor____ Major ____
Description of Incident: ___________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Treatment given: ________________________________________________________
Did you use the First Aid Kit? ______________________________________________
Did you use the cell phone to call for help? _____________________________________
Did your student need to go to the hospital? ____________________________________
Was EMS called? _______________________________________________________
Other important facts about this Incident? ______________________________________
Signature of Instructor in attendance_______________________ Date: ______________
Signature of witness_____________________________________ Date: ____________
|
