The ManKind Project International Created: 2005-03-06
Incident Report Form Page 2 of 2 Version: 2011-03-01
If you answer “Yes,” to any question below, please elaborate in the Comments section.
Is this a re-injury of a prior condition? Yes No
Did the Affected Party contribute to the incident in any way? Yes No
Did the Affected Party state that he contributed to the incident in any way? Yes No
Did anyone else contribute to the incident? Yes No
Were warnings or instructions not heeded? Yes No
Did the Affected Party refuse first aid or transport to medical care? Yes No
Did equipment contribute to the incident? Yes No
Does the Affected party have health insurance? Yes No
Insurance Company:
Insurance Policy Number:
Insurance Phone:
Insurance Address:
Were others injured or ill? (If so, complete a separate incident form for each.) Yes No
Could anything have been
done to prevent this injury?
Our intention is not to
assess blame, but to prevent
future injuries. Please be
specific and detailed.
Additional Comments:
If Incident Occurred Outdoors, Complete the Following
Describe Site of Incident:
Describe Weather:
Air Temperature: Wind:
Water Temperature: Precipitation:
Describe Any Other
Contributing Factors:
If Property Damage:
Describe Damages,
Estimated Value, and Cost
To Repair.
For serious injury or illness forward to the reports@mkp.org :
A copy of the Participant or Staff Release
A copy of the Confidential Medical Record
Photographs of the injury or site of incident if relevant
Names of Witnesses and signed Witness Statements
For men who leave the weekend for illness or injury or visit a hospital: Please check in with them during the week
following the training, and forward a brief follow-up report to reports@mkp.org.
Name: Title:
Signature: Date:
