Fillable MKPUSA Incident Report 2020-01-01

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MKPUSA Incident Report 2020-01-01

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The ManKind Project USA 2020-01-01
Incident Report Form Page 1 of 2
T
he ManKind Project USA
Incident Report
For death or life-threatening emergency, call one of the MKP USA Emergency
Contacts IMMEDIATELY.
Please complete this report by filling it out electronically with Adobe Reader.
Save using Adobe Reader and Email the report to reports@mkp.org wi
thin 48 hours of the incident.
Report should be submitted in editable pdf format. Not a scan of the document.
If additional pages are needed please type them into another document, save and email along with this report.
Complete a separate report for each individual affected.
In addition, please print and sign a copy for the Area Administrator to file and keep for 4 years.
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.
Area:
Event Date:
Event Facility:
Location:
Type of Event:
NWTA ST1 ST2 LT1 LT2 I&I IGFT Other
Type of Incident:
Injury Illness Property Damage Near Miss
Name of Person Injured / Affected:
Date of Birth:
Participant Staff MOS Visitor
Address:
Home
Phone:
Work
Phone:
Mobile
Phone:
Describe what happened
Leader/Presenter Overseeing Activity
Others 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 Volatile
Other:
Describe First Aid Given
Describe Evacuation/Transport
Condition on Departure From Training
Activity Time Lost None – 1 Hour 1 – 3 Hours Half Day or More Ended Participation
The ManKind Project USA 2020-01-01
Incident Report Form Page 2 of 2
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 MKP USA may request the following be sent to reports@mkp.org :
• A copy of the Participant or Staff Release
• Photographs of the injury or site of incident if relevant
• Names of Witnesses and signed Witness Statements
For those who leave the training 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:
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MKPUSA Incident Report 2020-01-01

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Completed 20 July 2020

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