Form Fdacs-03428 - Written Accident Report Form - Florida Department Of Agriculture And Consumer Services
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1Florida Department of Agriculture and Consumer Services
Division of Consumer Services/Bureau of Fair Rides Inspection
WRITTEN ACCIDENT REPORT
Section 616.242(14)(a), Florida Statutes, Rule 5J-18.0012, Florida Administrative Code
ADAM H. PUTNAM
Phone 1-800-435-7352; Fax (850) 410-3797; (PM) 800-663-3542
COMMISSIONER
ANY ACCIDENT FOR WHICH A PATRON IS TRANSPORTED TO A HOSPITAL MUST BE REPORTED BY
PHONE WITHIN 4 HOURS OF THE OCCURRENCE, FOLLOWED BY A WRITTEN REPORT WITHIN 24
HOURS TO THE DEPT. OF AGRICULTURE AND CONSUMER SERVICE, BUREAU OF FAIR RIDES
INSPECTION: 2005 APALACHEE PARKWAY, TALLAHASSEE, FL 32399-6500. PH (1-800-663-3542),
FAX (1-850-410-3797); E-MAIL:
Date of Accident: _______________________________
Time of Accident: __________ a.m.
p.m.
Amusement Ride Information:
Injured Patron Information:
Name of Amusement Ride Company: _______________
Was Patron transported or sought medical attention:
Yes
or
No
_____________________________________________
Name: _______________________________________
Address: _____________________________________
Age in years: ____ Gender: Male
Female
City: ________________________ State: ___________
Address: _____________________________________
Zip: _______ Ph. #: ___________ Fax # ____________
City: _________________________ State: __________
Name of Fair/Event/ Location: _____________________
Zip: ____________ Ph. #: ________________________
Address: _____________________________________
Parent/Guardian Name: _________________________
City: ________________________ State: ___________
Describe injury(s): ______________________________
County: ______________________________________
_____________________________________________
Phone number where person completing report can be
_____________________________________________
reached: _____________________________________
_____________________________________________
Amusement Ride name:__________________________
_____________________________________________
USAID #: _____________________________________
_____________________________________
Name of Operator: _____________________________
_____________________________
__________
Did accident occur on ride: Yes
No
If yes, describe how accident occurred. If no, where did
accident occur?
Witness Name:
____________________________________________
_____________________________________
_____________________________________________
Address: _____________________________________
_____________________________________________
City: ____________________ State: _______________
____________________________________
__
Zip: ___________Ph #: __________________________
Write additional information on back
Print Name of Person Completing Report
Signature
Date
FDACS-03428 Rev. 01/09
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