Incident Report Form (pdf)

INFORMATION ON INJURED PERSON OR OWNER OF DAMAGED PROPERTYName:Birth date:Address:Phone Numbers: Home: Work:Complete this section ifthis person is aregistered member:Unit:Youth / Adult (Please circle one)Chartering Organization:Please describe natureof injury or propertydamageComplete if applicable: Name of doctor consulted: Phone:Complete if applicable: Name and address of hospital or clinic: Phone:REPORTING DETAILSThis report must besigned by a currentlyregistered Scoutingmember or a currentemployee.Fax to council officewhen competed; sendoriginal to______________Council,________________________,________________________Print full name:Position in Scouting:Street Address:Town, State, Zip:Telephone (Home)Fax:(work)Email:Signature:Date: