Fillable Camp/Competition Incident Report Form (Lamar University)

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Camp/Competition Incident Report Form (Lamar University)

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The Camp/Competition Incident Report Form (Lamar University) form is 2 pages long and contains:

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File type: PDF

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Camp/Competition Incident Report Form
Camper’s Name_______________________________________________________ Date _____________
Address _______________________________________________________________________________
Street City State Zip code
Name of Person Involved _________________________________________________________________
Last First Middle
Age ________ Sex ________ Position: Camper Paid Staff Volunteer Staff Visitor
Address _______________________________________________________ Phone: __________________
Street City State Zip code
Name of Parent/Guardian (if Minor)____________________________________________________________
Address _______________________________________________________ Phone: __________________
Street City State Zip code
Names/Addresses of Witnesses
1. ____________________________________________________________________________________
2. ____________________________________________________________________________________
3. ____________________________________________________________________________________
Type of Incident: Behavioral Accident Epidemic Illness Other _______________________
Date of Incident/Accident____________________________________________ Time: ___________ am pm
Describe the Event and details of the injured person:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Where did it occur? Be specific and use locations and names of witnesses:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________________
Was injured participating in an activity at the time of injury? Yes No If yes, what activity? _____________
Was any equipment involved in the accident? Yes No If so, what kind? ____________________________
What could the injured have done to prevent the injury? ____________________________________________
Describe the emergency procedures followed at the time of the incident/accident:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Who was in charge? _________________________________________________________________________
Form submitted by: _______________________________ Position ___________________ Date ___________
Phone Number: __________________________________
Lamar University
Office of EHS & Risk Management
P.O. Box 10807
Beaumont, TX 77710
Fax - 880-7977
Camp/Competition Incident Report Form (Page 2)
Were the parents notified? Yes No
By whom? ________________________________ Title: ___________________________ When: __________
Parent’s response: __________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Where was treatment given? At accident Health Center Doctor’s Office Hospital
What was the nature of the treatment?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
By Whom? ____________________________________ Title: ______________________________________
Was treatment was given other than at camp? Yes No
If yes, what hospital or doctors office? __________________________________________________________
Name of attending phsycian: __________________________________________________________________
Comments:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________________
Lamar Officials Notified:
Name Position Date/Time
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Describe any contact from the media:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Form submitted by: _______________________________ Position ___________________ Date ___________
Phone Number: __________________________________
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CampCompetition Incident Report Form (Lamar University)

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Completed 22 August 2020

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