Appendix 9.8.

4 – Accident / Incident Report Form

(This form is to be completed for all employee, patron and visitor accidents /incidents)

INSTRUCTIONS: All venue-related accidents/incidents (employee, patron, visitor, etc) require Sections I and
II of this Accident/Incident Report to be completed by management or another employee of the venue. The
injured person should not complete this report. Management is required to complete Section III on the
reverse side, review the report for completeness and accuracy, sign and log this report in the
accident/incident log book within 24 hours of the accident/incident. Note: the report (and pictures if any)
should then be filed together in a safe and secure location of the venue. Any copies of this report and any
other related materials in conjunction with this report cannot be obtained without the authorization of
management.
SECTION I PLEASE PRINT OR TYPE ALL INFORMATION

NAME: ___________________________________________________ _____________________________________

(Brief Physical Description)
HOME ADDRESS:
___________________________________________________________________________________________________
Number/Street City State Zip
TELEPHONE NUMBER: ( )_____________________ AGE: ________ DATE OF BIRTH ______________
(required by insurance agency)
_____ EMPLOYEE _____ PATRON _____ VISITOR (reason for being on premises)___________________________________

SECTION II ACCIDENT DATA

____ Accident/Injury ____ Theft/Burglary
NATURE OF INCIDENT: ____ Physical Altercation ____ Verbal Confrontation
____ Property Damage ____ Other

DATE OF Accident /Incident: __________ TIME of Accident /Incident: _____________ ____AM ____PM

Accident /Incident occurred at: __Inside Venue__ Outside Venue __ Other Location (Specify Location) ________________________
Specific Location of Accident: __________________________________________________________________________________
(Address / Vicinity / Actual Location)
Briefly explain what happened: (if an injury, (1) explain activities occurring when injury or illness occurred and what tools, machinery, chemicals, weapons,
were involved, (2) what happened to cause this injury or illness (3) what was the injury or illness (i.e., state the part of body affected and how it was affected) Use
additional paper if needed.
_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

What action was taken: Check all actions taken. If more than one, indicate which occurred 1st, 2nd, etc.
_______ First Aid – administered by _____________________________________________
_______ Sent to Hospital/Physician (Name of Hospital/Physician) ____________________________________________________
_______ Pictures Taken (Number of Pictures Taken) _________________________________
_______ Sent Home
_______ Continued Activity (no action taken)

Venue Contact/Management: __________________ Name of Witness (if applicable) _______________ Phone: __________

Person Completing the Report _________________________________________________________ Date: ____________

Reviewed by Venue Owner/Risk Manager _____________________________________________ Date: ____________

Return form same day (or within 24 hours) of accidents/incident for employee, patron, or visitor to
the corresponding Risk Owner, or Dr. Lipsett.
Accident/Incident Report Form page 2

SECTION III MANAGEMENT/SUPERVISOR REPORT ON THE ACCIDENT/INCIDENT

What action has been taken to prevent such an accident/incident from recurring? Include specific details on how it was
mediated, how the incident can be avoided in the future. (Note that photos are highly recommended immediately following an
incident, if at all possible.)
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

Management/Supervisor’s Account of Incident which supplements and/or clarifies information provided by injured party: (if an
injury, (1) explain activities occurring when injury or illness occurred and what tools, machinery, chemicals, were involved, (2) what happened to cause this injury or
illness (3) what was the injury or illness (i.e., state the part of body affected and how it was affected)

_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

Section III Completed by: ____________________________________________ ___________________

Signature Date
SECTION IV- FOR INVESTIGATION/REVIEW ONLY - DO NOT WRITE BELOW THIS LINE:
Investigation Comments: Photos are highly recommended immediately following an incident, if at all possible.

Required Action:

Location Code: ____

Section IV Completed by: ____________________________________________ ___________________

Signature Date
Date sent to management: ________________ other ___________________________

3/22/11 Courtesy of BouncerOnline