Accident or Incident Report | Girl Scouts GCNWI

When an accident or incident occurs that requires more than routine care, the incident must be reported through an Accident/Incident Report.

Girl Scouts of Greater Chicago and Northwest Indiana considers an accident to be an incident that occurs, resulting in damage or injury to a person. Not all accidents warrant an Accident/Incident report such as in the case of minor instances— ex. bumps and bruises, minor lacerations requiring no more than a band-aid or basic first aid. If an accident occurs that requires more advanced care (even after the event) or prolonged time to heal, an Accident/Incident form should be completed as soon as possible.

GSGCNWI considers an incident to be an atypical occurrence that is the result of improper conduct by a girl or adult which warrants additional support. An incident may be the result of a broken policy/procedure, inappropriate behavior, and/or a failure to follow the Girl Scout Promise and Law. If emergency services are contacted, an incident report should be completed.

Location of accident/incident *

Street Address *

City *

State *

Zip Code *

What is the nature of the accident/incident? *

Describe where on this site the accident/Incident took place. i.e. "In the cabins, near the lake". *

Accident/incident reported by whom? *

Date of accident/incident * +

Time of accident/incident *

Group/Troop Leader & Organization

Group Leader's First Name *

Group Leader's Last Name *

Organization: *

Position: *

Witness(es)

How many witness statements do you have? *

1- First Name of Witness *

1- Last Name of Witness *

1- Relationship to injured *

1- Daytime phone *

1- Evening phone *

1- Cell phone *

1 - Attach a signed statement from witness 1

2 - First Name of Witness *

2 - Last Name of Witness *

2 - Relationship to injured *

2 - Daytime phone *

2 - Evening phone *

2 - Cell phone *

2 - Attach a signed statement from witness 2

3 - First Name of Witness *

3 - Last Name of Witness *

3 - Relationship to injured *

3 - Daytime phone *

3 - Evening phone *

3 - Cell phone *

3 - Attach a signed statement from witness 3

More than 3 - Attach a signed statement from additional witnesses.
Please include full name of witness and phone number along.

Action taken

What happened? (Be specific including sequence of events): *

Was 911 called? *

Yes

No

Who called 911? *

When was 911 called? *

What did you do? (Be specific, include sequence of events): *

Was property or equipment damaged? *

Yes

No

Please explain property or equipment damaged: *

Is the cause of the accident/incident known? *

Yes

No

Suspected cause of accident/incident: *

Describe any contact with the media regarding this situation: *

Was Girl Scouts staff notified? *

Yes

No

Girl Scout staff notified:

	Staff notified	By Whom	How	When
1	Staff notified	By Whom	How	When
2	Staff notified	By Whom	How	When
3	Staff notified	By Whom	How	When

Complete this section if person(s) was injured

Was anyone injured? *

Yes

No

How many persons were injured? *

1 - First Name of Injured *

1 - Last Name of Injured *

1 - Age of injured *

1 - Gender of injured: *

1 - Troop/Group # of injured *

1 - Was treatment given to this person? *

Yes

No

1 - Treatment given by: *

1 - Type of treatment given? *

1 - Treatment given where? *

1 - EMT Name *

1 - Attending physician *

1 - Was person(s) transported? *

Yes

No

1 - Transported by whom? *

1 - Transported how *

1 - Where was this person transported to? *

1 - Was the parent/guardian notified? *

Yes

No

1 - Full Name of Parent/guardian: *

1 - Notified how? *

1 - Notified by when? *

1 - Notified by whom? *

1 - Response from parent/guardian *

2 - First Name of Injured *

2 - Last Name of Injured *

2 - Age of injured *

2 - Gender of injured: *

2 - Troop/Group # of injured *

2 - Was treatment given to this person? *

Yes

No

2 - Treatment given by: *

2 - Type of treatment given? *

2 - Treatment given where? *

2 - EMT Name *

2 - Attending physician *

2 - Was person(s) transported? *

Yes

No

2 - Transported by whom? *

2 - Transported how *

2 - Where was this person transported to? *

2 - Was the parent/guardian notified? *

Yes

No

2 - Full Name of Parent/guardian: *

2 - Notified how? *

2 - Notified by when? *

2 - Notified by whom? *

2 - Response from parent/guardian *

3 - First Name of Injured *

3 - Last Name of Injured *

3 - Age of Injured *

3 - Gender of injured: *

3 - Troop/Group # of injured *

3 - Was treatment given to this person? *

Yes

No

3 - Treatment given by: *

3 - Type of treatment given? *

3 - Treatment given where? *

3 - EMT Name *

3 - Attending physician *

3 - Was person(s) transported? *

Yes

No

3 - Transported by whom? *

3 - Transported how *

3 - Where was this person transported to? *

3 - Was the parent/guardian notified? *

Yes

No

3 - Full Name of Parent/guardian: *

3 - Notified how? *

3 - Notified by when? *

3 - Notified by whom? *

3 - Response from parent/guardian *

4 - First Name of Injured *

4 - Last Name of Injured *

4 - Age of Injured *

4 - Gender of injured: *

4 - Troop/Group # of Injured *

4 - Was treatment given to this person? *

Yes

No

4 - Treatment given by: *

4 - Type of treatment given? *

4 - Treatment given where? *

4 - EMT Name *

4 - Attending physician *

4 - Was person(s) transported? *

Yes

No

4 - Transported by whom? *

4 - Transported how *

4 - Where was this person transported to? *

4 - Was the parent/guardian notified? *

Yes

No

4 - Full Name of Parent/guardian: *

4 - Notified how? *

4 - Notified by when? *

4 - Notified by whom? *

4 - Response from parent/guardian *

5 - First Name of Injured *

5 - Last Name of Injured *

5 - Age of injured *

5 - Gender of injured: *

5 - Troop/Group # of injured *

5 - Was treatment given to this person? *

Yes

No

5 - Treatment given by: *

5 - Type of treatment given? *

5 - Treatment given where? *

5 - EMT Name *

5 - Attending physician *

5 - Was person(s) transported? *

Yes

No

5 - Transported by whom? *

5 - Transported how *

5 - Where was this person transported to? *

5 - Was the parent/guardian notified? *

Yes

No

5 - Full Name of Parent/guardian: *

5 - Notified how? *

5- Notified by when? *

5 - Notified by whom? *

5 - Response from parent/guardian *

More than 5 - Please include full name of answer questions on a separate sheet of paper and upload them for the remaining injured.

Are there others involved in the accident/incident *

Yes

No

List of others involved in the accident/incident.

	Full Name of injured	Age	Gender	Group #
1	Full Name of injured	Age	Gender	Group #
2	Full Name of injured	Age	Gender	Group #
3	Full Name of injured	Age	Gender	Group #
4	Full Name of injured	Age	Gender	Group #
5	Full Name of injured	Age	Gender	Group #

Report completed by:

First Name *

Last Name *

Organization *

Position *

Phone Number *

Email Address *

Completed on * +

I believe this information to be true and correct to the best of my knowledge *

I agree

Signature of person completing this report. (please type your full name) *