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Non-Staff Incident Report

2. Incident Report (Internal Non-Staff)

6. Incident Details

8. Report Date*
   Report Date

9. Incident Date/Time*
   Incident Date/Time

   Incident Date/Time

11. Facility*
    -- Select One --Aquatics ComplexBRCC (indoor)BRCC Grounds (outdoor)Lakeside Center

12. Exact Location*

14. Incident Type*

    1. Injury
    2. EMS

    1. Police
    2. Theft

    1. Damage

    1. Interaction with Public
16. Name of Staff who Prepared Incident Report*

17. Did Staff Member Witness the Incident?*

    1. Yes

    1. No
19. Description of Incident*

    Please be specific but only report facts.

23. Patron Information

25. Last Name*

26. First Name*

27. Date of Birth
    Date of Birth

28. Gender

    1. Male
    2. Female

30. Address*

31. Phone #*

33. City

34. State

35. Zip

39. Police/EMS

41. Was a police report written?*

    1. Yes
    2. No

42. Case #

43. Officer name and/or badge #

45. Was EMS involved?*

    1. Yes
    2. No

46. Did patron accept/decline transportation to a medical facility?*

    1. Accept
    2. Decline
    3. N/A

48. If accepted, which facility were they transported to?

49. If declined, did the patron return to activity?

    1. Yes

    1. No

53. Incident Documentation

55. Upload Document or Photo

57. Upload Document or Photo

Leave This Blank:


58. Submit

* indicates a required field