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%
33%
50%
66%
83%
100%
Place of Incident
16%
33%
50%
66%
83%
100%
Where on the property did the incident occur?
16%
33%
50%
66%
83%
100%
Person Reporting
16%
33%
50%
66%
83%
100%
Phone
16%
33%
50%
66%
83%
100%
Email of Person Reporting
16%
33%
50%
66%
83%
100%
16%
33%
50%
66%
83%
100%
INJURED PARTY'S INFORMATION:
16%
33%
50%
66%
83%
100%
Injured's Name
16%
33%
50%
66%
83%
100%
Select One
Team Member
Team Volunteer
Event Volunteer
Other
16%
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%
83%
100%
Injured's City
16%
33%
50%
66%
83%
100%
State
16%
33%
50%
66%
83%
100%
Zip
16%
33%
50%
66%
83%
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%
16%
33%
50%
66%
83%
100%
Upload Any Supporting Documents or Images
Select Files (Click to add files)
16%
33%
50%
66%
83%
100%
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