Incident/Injury Report Form
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In the event of injury while volunteering,
please notify City of Oakland staff immediately at
adoptaspot@oaklandnet.com, 510-238-7630.
1.
2017
M F
Address of Injured Person and Best Contact Phone Number (Include Area Code)
If Applicable, Parent’s Name, Address, and Best Contact Phone Number (Include Area Code)
Date and Time of Accident
Place where Accident Occurred
Type of Injury suspected if known (Check any that apply):
Bruise Dislocation Laceration Concussion Fracture Sprain/Strain
Ot
her(Specify)
Body Part Injured (Note side of Injury using “R” for Right side and “L” for Left Side)
H
and Foot Arm Shoulder Back Head Face Foot Leg Chest Eye
Ot
her(Specify)
Was First Aid rendered? Describe if yes:
Was an Ambulance recommended? Yes No
If yes, did the injured refuse? Yes No
Were teeth injured? If so, which ones?
Describe Condition of Injured Teeth Prior to Accident:
Whole, Sound, and Natural Filled
Capped
Artificial
Did Injury Result in Death? Yes No
Describe How Accident Occurred – Give All Possible Details
Pr
int Name_________________________________________________ Signature _______________________________________________
Date ____________________________________________________
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signature
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