16%
33%
50%
66%
83%
100%
16%
33%
50%
66%
83%
100%
Rep
ort
of
Medical Incident:
CONFIDENTIAL
16%
33%
50%
66%
83%
100%
All physical injuries/illnesses, however slight, taking place at a
FIRST
event must be reported to
FIRST
Headquarters.
16%
33%
50%
66%
83%
100%
Program Type:
FRC
FTC
FLL
Other
16%
33%
50%
66%
83%
100%
Date of Incident
16%
33%
50%
66%
83%
100%
Event Name
16%
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50%
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100%
Place of Incident
16%
33%
50%
66%
83%
100%
Where on the property did the incident occur?
16%
33%
50%
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83%
100%
Person Reporting
16%
33%
50%
66%
83%
100%
Phone
16%
33%
50%
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100%
Email of Person Reporting
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33%
50%
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100%
16%
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50%
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100%
INJURED PARTY'S INFORMATION:
16%
33%
50%
66%
83%
100%
Injured's Name
16%
33%
50%
66%
83%
100%
Injured Affiliation
Student
Mentor
Event Volunteer
Spectator
Other
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33%
50%
66%
83%
100%
Team Number
16%
33%
50%
66%
83%
100%
16%
33%
50%
66%
83%
100%
Injured's Street Address
16%
33%
50%
66%
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100%
Injured's City
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100%
State
16%
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50%
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100%
Zip
16%
33%
50%
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100%
Injured's Phone Number
16%
33%
50%
66%
83%
100%
A Minor? Parent/Guardian Name
16%
33%
50%
66%
83%
100%
If minor, was parent present?
Yes
No
16%
33%
50%
66%
83%
100%
Injured Body Part(s):
16%
33%
50%
66%
83%
100%
Nature of Injury:
16%
33%
50%
66%
83%
100%
Medical Care Given/Action Taken
16%
33%
50%
66%
83%
100%
Disposition
Ambulance to Hospital
Personal Auto to Hospital
Returned to Event
Refused Treatment
16%
33%
50%
66%
83%
100%
16%
33%
50%
66%
83%
100%
WITNESS INFORMATION
16%
33%
50%
66%
83%
100%
Witness Name and Contact Info
16%
33%
50%
66%
83%
100%
Witness Name and Contact Info
16%
33%
50%
66%
83%
100%
16%
33%
50%
66%
83%
100%
Witness' Description of Events
16%
33%
50%
66%
83%
100%
INCIDENT STORY AND NARRATIVE
16%
33%
50%
66%
83%
100%
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33%
50%
66%
83%
100%
16%
33%
50%
66%
83%
100%
PLEASE UPLOAD ANY SUPPORTING DOCUMENTS OR IMAGES:
16%
33%
50%
66%
83%
100%
For injuries involving a trip/slip & fall, please include pictures of the location where the individual tripped or slipped.
Select Files (Click to add files)
16%
33%
50%
66%
83%
100%
16%
33%
50%
66%
83%
100%
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