Incident/Accident Report and Assesment in PDF format
Incident/Accident Report and Assesment in MS Word format

To be completed by field trip leader in the event of an incident involving serious injury
and/or damage to property, and filed with LOC Safety Officer or Section/Division Head or

Name of Person Involved (PRINT)
Date of Occurrence
First Aid or Medical Attention Required: 
Yes: _____         No: _____
Damage to Equipment:
     Yes: _____         No: _____
Field Trip Leader's Name
Field Trip Leader's Signature
Report Date
Reported By
Reported To (police, other authority)
Copy Sent to GAC Safety Committee 
Date of Notification
Field Trip Participant's Signature
Workers Compensation Form Completed?
  Yes: _____          No: ______
   (If Yes, Please Attach Copy)
Date of Completion of Form
Location of Occurrence (Outcrop, Highway, City, etc.)
Other Personnel Involved in Incident/Accident
Field Trip Participant's Report of Incident/Accident. Describe Activity That Led to Incident/Accident Stating What Equipment (e.g., tools, etc.) Was Involved. Describe the Nature and Cause of the injury.


Are There Any Witnesses?  Yes: _____         No: ______
Names and Addresses of Witnesses

Statements of Witnesses First on Scene of Incident/Accident
Statements of Other Witnesses

If more space is required use a separate sheet of paper.

Last modified: May 2, 2010
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