HomeMy WebLinkAboutIncident Report_4.7.26 City of Diamond Bar
Parks and Recreation - Accident/Incident Report
Personal Information (Injured/Involved party):
Date: Program:
Name: Age: Phone:
Address: City/Zip:
Witness to Accident/Incident:
Name: Phone:
Accident/Incident information:
Where did incident occur:
Staff Present: Time:
Briefly Describe What Happened (Be Concise):
Injury and/or Family Contacted (if applicable)?
Describe the nature of their Injury:
Name/Phone: Result:
Time Picked up: Date of Return to Program:
City of Diamond Bar
Parks and Recreation - Accident/Incident Report
Action Taken - Please complete the following as applicable:
911/Dispatch
Contacted ? Yes No Yes No Sheriff Arrive? Yes No
Case/Tag #: Deputy Name:
Video Footage Available?
Yes No
Camera(s)
_____________ and ______________
_____________ and ______________
Time(s)
______ - ______ &______ - ______
______ - ______ &______ - ______
Follow Up Comments or Actions: ( Parents' Reaction/Update on Injured Participant)
Staff Signature: Date:
Additional Comments
Supervisors Comments:
Signature: Date:
Superintendents Comments:
Signature: Date:
Directors Comments:
Signature: Date:
Ambulance Arrive?