Rep
ort
of
Medical Incident:
CONFIDENTIAL
All physical injuries/illnesses, however slight, taking place at a
FIRST
event must be reported to
FIRST
Headquarters.
Program Type:
FRC
FTC
FLL
Other
Date of Incident
Event Name
Place of Incident
Where on the property did the incident occur?
Person Reporting
Phone
Email of Person Reporting
INJURED PARTY'S INFORMATION:
Injured's Name
Injured Affiliation
Student
Mentor
Event Volunteer
Spectator
Other
Team Number
Injured's Street Address
Injured's City
State
Zip
Injured's Phone Number
A Minor? Parent/Guardian Name
If minor, was parent present?
Yes
No
Injured Body Part(s):
Nature of Injury:
Medical Care Given/Action Taken
Disposition
Ambulance to Hospital
Personal Auto to Hospital
Returned to Event
Refused Treatment
WITNESS INFORMATION
Witness Name and Contact Info
Witness Name and Contact Info
Witness' Description of Events
INCIDENT STORY AND NARRATIVE
PLEASE UPLOAD ANY SUPPORTING DOCUMENTS OR IMAGES:
For injuries involving a trip/slip & fall, please include pictures of the location where the individual tripped or slipped.
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