The ManKind Project International Created: 2005-03-06
Incident Report Form Page 1 of 2 Version: 2011-03-01
The ManKind Project International
Incident Report
For death or life-threatening emergency, call one of the MKP Emergency Contacts
Please complete this report electronically with the same attention to detail you would use in your own practice.
Attach additional pages if needed. Email the report to within 48 hours of the incident.
In addition, please print and sign a copy for the Regional or Center Director to file.
Click or Tab to blank area of each text box to begin typing in this electronic PDF form.
The cells will expand internally and scroll, if needed, as you type.
Region or Center:
Training Date:
Training Facility: Location:
Type of Training: NWTA ST1* ST2 LT1 LT2 LT3 I&I IPLT *formerly BSDT
Type of Incident: Injury Illness Property Damage Near Miss
Person Injured or Affected: Age:
Participant Staff MOS Visitor
Activity During Which Incident Occurred:
Date & Time of Incident:
Describe what happened
Certified Leader Overseeing Activity
Staff Directly Involved
If Injury or Illness, the Medic Must Complete The Following
Describe Injury or Illness (physical exam)
Describe Mental Status
Select All That Apply
Confused Calm Panicked Aggressive
Describe First Aid Given
Describe Evacuation/Transport
Condition on Departure From Training
Activity Time Lost None Less than 1 Hour ½ Day or More Ended Participation
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 :
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
Name: Title:
Signature: Date: