Incident/Accident Reporting Form

Incident/Accident Reporting Form

If this matter requires immediate attention, please contact Anita Bullitt (502-445-4394) or William Strader (502-777-4598). Information reported on this form should be legible, factual and to the point. No one should undertake an additional investigation into the reported matters without authorization and/or the direction of GSK staff. Any sensitive communications should be handled or directed by GSK staff. If the reporting party is unsure about how to proceed or how to properly complete the form, he or she should contact GSK staff immediately.
Section 1 - Event/Activity Information
Event/Activity Name*
Event/Activity Date*

MonthDayYear
Date
Event/Activity Location*
Section 2 - Contact Information for Person Involved in the Incident
Full Name*

First NameLast Name
Age*
Sex*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Day Phone*

Area CodePhone Number
Alt. Phone*

Area CodePhone Number
Was this person:(Choose all that apply)*

Girl (under age 18)AdultGirl Scout MemberPaid Staff
Section 3 - Witnesses
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Section 4 - Incident/Accident Information
Type of Incident*

BehavioralAccidentEpidemic IllnessOther
Date and Time of Occurrence*

YearMonthDay
DateHourMinutesAM/PM Option
Describe the incident in detail, including what the involved person(s) was (were) doing at the time:*
Were the parents notified?*

YesNo
When were they notified?*
What was the parents' response?*
Describe any hazardous or potentially hazardous conditions:*
Where did the incident occur? Include location of all involved persons. You may upload a picture below to illustrate.*
What emergency procedures were followed at the time of the incident?*
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Section 5 - Form Submitted by
Name/Position*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Optional - Upload Photo

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