CITY OF ALABASTER PARKS & RECREATION DEPARTMENT ACCIDENT REPORT FORM Injured Person:
9 Athlete
9 Coach
9 Volunteer
9 Spectator
9 Other___________________________ Type Claim: 9 Personal Injury
9 Fatality
9 Property Damage
9
Other_____________________________
CLAIMANT Injured
Person
Name:____________________________________________________________________________________ ________ Address: _________________________________________________________________________________________ ______________ City,
State,
Zip:
_________________________________________________________________________________________ ________ Phone
#:
Home:(_____)_____________________Work:(_____)______________________Beeper:(_____)________ _____________ Date
of
Birth:________/________/________
9
Sex:
Male
9
Female
SS#:________________________________________
RESPONSIBLE PERSON/PARENT/GUARDIAN Name:_______________________________________________________________Relationship:________ ______________________ Address: _________________________________________________________________________________________ ______________ City,
State,
Zip:
_________________________________________________________________________________________ ________ Phone
#:
Home:(_____)_____________________Work:(_____)_____________________Beeper:(_____)_________ _____________ Employer:________________________________________________________________________________ _____________________ Address:_________________________________________________________________________________ _____________________ Does the injured person have medical insurance?
9 Yes
9
No
If
yes,
name
of
policy
holder:_________________________________________Policy
Number:________________________________ Insurance Company__________________________________________________________________________________ _____
DESCRIPTION OF THE ACCIDENT Date of accident:________/________/________ 9 a.m.
accident:____________________________ Exact
Time
of
9 p.m.
location
where
accident
occurred:_____________________________________________________________________________ What
sport/activity
was
the
person
participating
in:___________________________________________________________________ 9 Practice
Did this take place during:
how
accident
9 While
9 other_______________
traveling to/from event Describe
9 Competition
happened,
including
details
of
events
that
led
up
to
accident:________________________________________ _________________________________________________________________________________________ ____________________ _________________________________________________________________________________________ _____________________ _________________________________________________________________________________________ ______________________ _________________________________________________________________________________________ ______________________ Describe condition of equipment and/or surrounding area at the time of the accident. Note
weather
conditions,
type
of
supervision,
nature
of
the
activity,
etc.:____________________________________________________________________________________ ____ _________________________________________________________________________________________ ______________________ _________________________________________________________________________________________ ______________________ If an item of play equipment is involved, be very specific as to what component was involved in the accident:____________________ _________________________________________________________________________________________ ______________________ _________________________________________________________________________________________ ______________________ (over)
INJURY
What
part
of
the
injured
person's
body
was
injured?__________________________________________________________________ 9 Severe cut w/ bleeding
Type of injury: 9 Break/fracture 9
9 Less serious bruise or cut
9 Concussion 9
Paralysis
9
Death
Other____________________________________________________________ Describe
the
injury:__________________________________________________________________________________ ____________ _________________________________________________________________________________________ ______________________ _________________________________________________________________________________________ ______________________ Treatment: Describe
treatment
provided
on
site:________________________________________________________________________________ _________________________________________________________________________________________ _____________________ List
persons
giving
First
Aid
on
site
(paramedic,
parent,
staff,
etc.)_______________________________________________________ Describe
treatment
provided
off
site:______________________________________________________________________________ _________________________________________________________________________________________ _____________________ Give
name,
address
and
telephone
number
of
facility
providing
treatment
to
injured
person:____________________________ _________________________________________________________________________________________ _____________________ _________________________________________________________________________________________ _____________________ How
was
injured
person
transported
to
off
site
facility?_____________________________________________________________
PROPERTY DAMAGE Please
describe
property
damaged:______________________________________________________________________________ _________________________________________________________________________________________ _____________________
WITNESSES Name
of
Witness:_________________________________________________________________________________
____________ Address: _________________________________________________________________________________________ __________ City,
State,
Zip:
_________________________________________________________________________________________ ___ Phone
#:
Home:(_____)____________________Work:(_____)____________________Beeper:(_____)___________ _________
Name
of
Witness:_________________________________________________________________________________ ____________ Address: _________________________________________________________________________________________ __________ City,
State,
Zip:
_________________________________________________________________________________________ ____ Phone
#:
Home:(_____)____________________Work:(_____)____________________Beeper:(_____)___________ __________
PHOTOGRAPHS Photographs
of
injury
or
damaged
property
taken
by:_____________________________________________________________
Name
of
Person
completing
report:____________________________________________________________________________ Title
of
person
completing
report:____________________________________________
Date:___________________________ Phone
#:
Home:(_____)______________________Work:(_____)_____________________Beeper:(_____)________ _____________
Signature:_______________________________________________________________________________ ___________________