The ManKind Project USA 2020-01-01
Incident Report Form Page 1 of 2
he ManKind Project USA
For death or life-threatening emergency, call one of the MKP USA Emergency
Please complete this report by filling it out electronically with Adobe Reader.
Save using Adobe Reader and Email the report to email@example.com 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.
NWTA ST1 ST2 LT1 LT2 I&I IGFT Other
Injury Illness Property Damage Near Miss
Name of Person Injured / Affected:
Participant Staff MOS Visitor
Activity During Which Incident Occurred:
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
Describe First Aid Given
Condition on Departure From Training
Activity Time Lost None – 1 Hour 1 – 3 Hours Half Day or More Ended Participation