Reporting a Serious Incident………………………………………………………19 Appendix A – Confidential Crisis Report Part I

APPENDIX A INTERNAL USE Girl Scouts Carolinas Peaks to Piedmont CONFIDENTIAL CRISIS REPORT: PART l

This confidential report is used to record all information concerning major emergencies, serious accidents or fatalities. Copies of this report should be sent or hand delivered to all members of the Crisis Team. Circulation of this information is limited and copies should be distributed in sealed envelopes marked personal and confidential.

DATE/TIME OF FIRST CALL OR REPORT PERSON WHO CALLED (Identify position) OR REPORTED INCIDENT TO YOU NAME TELEPHONE WHERE CALLING FROM TELEPHONE GIRL SCOUT PERSON AT THE SCENE NATURE OF EMERGENCY (accident, death, media item)

WHAT HAPPENED? (Be specific)

WHEN AND WHERE DID IT HAPPEN? – DATE/TIME/EXACT PLACE OF ACCIDENT

WAS THE PERSON TAKEN FOR MEDICAL TREATMENT? WHERE AND HOW?

NAME, AGES, ADDRESSES AND PHONE NUMBERS OF PEOPLE INVOLVED (If troop, include troop number, program age level, name of leader and indicate if member or nonmember.)

PARENTS’ NAME, ADDRESS OR ADDRESSES, PHONE NUMBER OR NUMBERS

OTHERS INVOLVED – POLICE, FIRE, MEDICAL AID, ETC. Name of Department City/County/State Contact Person Telephone Number

CAUSE OF ACCIDENT OR OCCURRENCE (If known. Nature of transportation involved, details on owners, operators, license numbers)

WITNESSES – Those who were present or observed occurrence (include names, address and telephone numbers).

Report made to council office: (NAME, POSITION)

Report completed by: (NAME, POSITION)

DATE _____________

TIME _____________

CRISIS TEAM CALLED? YES NO If YES, go to Part II; if NO, why?

RECORD ANY OTHER ACTION TAKEN TO THIS POINT.

HOW WAS THIS RESOLVED?

SIGNATURE DATE

Once this information has been collected and the emergency is stable, the Crisis Team member should complete the form found in Appendix B: Confidential Crisis Report II.