Fillable Bsa Incident Reporting Tool printable pdf download

Incident Reporting Tool

(Events or allegations of injury, illness, or property damage, including employment and directors and officer’s issues)

General Incident Details

*Required Fields

*Incident Date: ________________________________ Incident Time (in 24-hour format): ______________________________________

*Report Date: _______________________________________________________________________________________________________

Date Reported to Council/BSA Location: ______________________________________________________________________________

Reported by Name: _________________________________________________________________________________________________

Reported by Primary Phone: ______________________________ Reported by Secondary Phone: _____________________________

Reported by Email: __________________________________________________________________________________________________

Reported by Address: _______________________________________________________________________________________________

Reported by City: _________________________________ Reported by State: __________ Reported by Zip Code: _______________

*Council/BSA Location: ______________________________ *Location of Incident: ___________________________________________

Specific area where incident occurred: ________________________________________________________________________________

Incident Address: ___________________________________________________________________________________________________

Incident City: _____________________________________ *Incident State: ______________ Incident Zip Code: ___________________

*Description of Incident (clear/concise/complete facts):

Was an Agency or Authority Notified?

❏ Yes

❏ No

Whom: ____________________________________________________

Injury/Illness/Damage Information

*Claimant Name: ____________________________________________________________________________________________________

Claimant Address: __________________________________________________________________________________________________

Claimant City: ____________________________________ *Claimant State: _____________ Claimant Zip Code: __________________

Claimant Primary Phone: ___________________________ Claimant Secondary Phone: _______________________________________

Claimant Email: _____________________________________________________________________________________________________

Claimant Date of Birth: _________________________________________ Age of Claimant: _____________________________________

General Classification (Cub Scout/Registered Leader/etc.): _____________________________________________________________

Chartered Organization: _____________________________________________________________________________________________

Property Damage?

❏ Yes

❏ No

Describe: __________________________________________________________________

Adventure/Program/Event: ___________________________________________________________________________________________

Bsa Incident Reporting Tool