Incident Report Form

							                                             Incident Report Form
                          University of Kentucky - Cooperative Extension Service
                                    4-H/Youth Development Programs
                                              212 Scovell Hall
                                         Lexington, KY 40546-0064

This incident report is required for significant behavioral problems or incidents at a range or
practice facility.

Name of Responsible Cooperative Extension Service office                                   Date of report ________
Name of Responsible Extension Service representative _______________________________________________
Address of office                                          State               Zip           Phone _____________
Name of involved person(s)                                                Age        Sex
Address                                                  State           Zip          Phone __________________
Name of involved person(s)                                                Age        Sex ______
Address                                                     State              Zip         Phone ________________
Name of Parent or Guardian (if minor)                                                           Age         Sex ___
Address                                                     State              Zip         Phone ________________
Name/Addresses of witnesses (Each witness should attach a signed statement of what happened.)
1. __________________________________________________________________________________________
2. __________________________________________________________________________________________
3. __________________________________________________________________________________________
Type of incident:
❑Behavioral                ❑Range Problem              □Other
Date of incident: Time             (a.m. or p.m.) Date                 Month               Year _____

Describe the incident in detail (use additional pages; if necessary)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Location of incident and diagram showing objects and persons
What activity was (were) the involved person(s) in at the time of the incident?




Describe any equipment involved in the incident


Describe emergency procedures followed, if necessary, as a result of this incident




                                             Medical Report of Incident

Were the parent(s) or guardian notified? ❑Yes ❑No
How?
By Whom?                                                      Title                                  When
Response of individual notified:




Was treatment required/given? ❑ At incident site      ❑ Doctor’s office/clinic    ❑ Hospital         ❑ Rescue squad

Describe treatment given:




Treatment given by whom?                                                          Date of treatment: _______________
Was injured retained overnight in hospital? ❑Yes ❑No If yes, where

Name of attending physician


Physician’s recommendation at the time of report



Revised 10/31/06
Comments




Other persons notified: (county agent, area program director, camping specialist, assistant director of 4-H, etc.)
Name                              Date                                         Position




Person completing report                                                                Signature _____________________________

Position                                                        Phone                                       Fax _____________________




Educational programs of Kentucky Cooperative Extension serve all people regardless of race, color, age, sex, religion, disability, or national
origin.




Revised 10/31/06
                                       INJURY AND ILLNESS REPORT
 Date:                                        Event
                                              Name:
 Date of Occurrence:

 Injured Person’s Name:                                                              Age:              DOB:                     Sex:

 Injured Person’s County:                                                            County Agent:

 Vital Signs:                                 Not Taken                              Patient’s Medications:

 Time:                                                                               Patient’s         None:
                                                                                     Allergies:
 BP:
                                                                                                       Unknown:
 Pulse:                                                                              Chief
                                                                                     Complaint:
 Temp:

 Case Narrative:
                                                                                                       Injury Area:




                                                                                                       Non-Injury:
                                                                                                       Apparent Fatal:

                                                                    INJURY
 Location:                         Type of Event Causing Injury:                                  Activity Causing Injury:
 __Parking Lot                     __Falling/Stumbling                                            Supervised -           Unsupervised -

 __Restroom                        __Collision w/ Person/Object                                   __Range                __Fighting

 __Clubhouse                       __Struck by Other Person                                       __Vehicle              __Horseplay

 __Range                           __Struck by Ammunition                                         __Clubhouse            __Walking
 Which one:____________

 __Vehicle                         __Bite/Sting by Insect/Spider                                  __Other ___________    __Running

 __Other (Specify)                 __Contact w/ Excessive Heat/Flame                                                     __Other (Specify)
                                                                                                                         _________________

                                   __Using a tool (including a cutting instrument)

                                   __Contact w/ a Sharp Object Other than a Tool

                                   __Other (Specify) _______________________________

                                                                   ILLNESSES
 Diagnosis (check no more than one)

 Infectious/Inflammatory Disease                                                      __External Wound

 __00 Toxic Disease (insect bites, poison ivy, drug use)                              __Appendicitis

 __01 Respiratory Infection                                                           __Homesickness

 __02 Gastroenteritis (diarrhea, vomiting)                                            __Miscellaneous/Other (Specify)

 __03 Dental (toothache, gum abscess, etc.)                                           __________________________________________

 __04 Earache/Ear Infection


Revised 10/31/06
                                      GENERAL INFORMATION
Was safety equipment available to injured person _____Yes _____No                      _____N/A
If yes, was person using it? _____Yes _____ No

 What treatment was given, list:                                   Was person sent to Medical Facility?

 1.                                                                _____Yes          _____No

 2.                                                                Names of those transporting person

 3.                                                                1.

 4.                                                                2.

 5.                                                                Was person sent by ambulance?

 6.                                                                _____Yes         _____No

 7.

 Where treated -

 __No treatment was given                                          __Treated in Clinic/Physician’s office

 __Treated in camp infirmary or first aid station                  __Admitted to hospital

 __Treated in hospital emergency room                              __Other (Specify) ____________________________

 Who made the diagnosis?                                           Disposition?

 __Physician                                                       __Complete recovery

 __Nurse                                                           __Temporary disability

 __E.M.T.                                                          __Permanent disability

 __Other (Specify) ______________________________                  __Unknown

                                                                   __Fatal




 Name(s) of witnesses to incident                                  Name(s) of volunteers present with person when treated

 1.                                                                1.

 2.                                                                2.

 Additional disposition or narrative to follow other medical attention. Comments.




 Completed by: _______________________________                     Nurse/E.M.T. # ________________________________

                             Signature

Revised 10/31/06
Revised 10/31/06