Incident/Accident Report

APPENDIX 5
INCIDENT/ACCIDENT REPORT AND ASSESSMENT

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
designate)


Name of Person Involved (PRINT) Date of Occurrence Time
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:
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.

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