Name of Injured Person
*
First Name
Last Name
Age
Gender
Please Select
Female
Male
Nonbinary
Other
Decline to Answer
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Troop #
Role
*
Please Select
Girl Scout
Girl Scout Volunteer
Non-Girl Scout
Paid Staff Member
Paid Staff Position
Name of Parent / Guardian (if minor)
First Name
Last Name
Parent / Guardian Address (if minor)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PART 1: Incident / Accident Information
Is this incident related to COVID-19?
*
Yes
No
Date of Positive Test
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Last Contact within Girl Scouts
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Was the location of your last contact on GSWO property?
Yes
No
GSWO Property Where Last Contact Occurred
Please Select
Girl Scout Service Center Toledo
Girl Scout Service Center Lima
Girl Scout Service Center Dayton
Girl Scout Service Center Cincinnati
Camp Butterworth
Camp Libbey
Camp Rolling Hills
Camp Stonybrook
Camp Whip Poor Will
Camp Woodhaven
Little House
Address Where Last Contact Occurred
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please list all individuals you were in close contact with (within 6 feet, with or without a mask)
Date and Time of Incident
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Did the incident occur on GSWO property?
Yes
No
GSWO Property Where Incident Occurred
Please Select
Girl Scout Service Center Toledo
Girl Scout Service Center Lima
Girl Scout Service Center Dayton
Girl Scout Service Center Cincinnati
Camp Butterworth
Camp Libbey
Camp Rolling Hills
Camp Stonybrook
Camp Whip Poor Will
Camp Woodhaven
Little House
Location of Incident
Address of Incident
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Description of Incident
*
Injury / Illness Location & Site
Body Part
Did the incident/accident occur during a Girl Scout sponsored activity?
Yes
No
Did the incident/accident occur while party was traveling to or from a Girl Scout activity?
Yes
No
Was the injured party participating in an activity at time of injury?
Yes
No
If so, what activity?
Was any equipment involved in incident/accident?
Yes
No
If so, what activity?
PART 2: Witnesses
Witness 1 Name
First Name
Last Name
Witness 1 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Witness 1 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Witness 2 Name
First Name
Last Name
Witness 2 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Witness 2 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PART 3: Treatment Summary
If treatment was given by first aider, doctor or emergency medical facility, describe below:
Was treatment given by first aider, doctor or emergency medical facility?
*
Yes
No
Where
By Whom
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Diagnosis
If Hospitalized, Name of Hospital
Date of Hospitalization
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Treatment Given
PART 4: Vehicles Involved
Were vehicles involved in the incident?
*
Yes
No
Was a second vehicle involved in the incident?
Yes
No
Driver Name
First Name
Last Name
Driver Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Driver Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Driver's License #
State of Driver's License
Vehicle Registration #
License Plate #
Insurance
Second Driver Name
First Name
Last Name
Second Driver Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Second Driver Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Second Driver's License #
State of Second Driver's License
Second Vehicle Registration #
Second License Plate #
Second Insurance
Report Issued By
Was a citation issued?
Yes
No
PART 5: Person Completing This Report
Your Name
*
First Name
Last Name
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Signature
*
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Please verify that you are human
*
Submit
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