Accident-Injury Report

This online submittable form is to be used to report any incident, injury or accident. Complete and submit this  form to the Risk Management Department at Insurance@gsnorcal.org within 24 hours of the incident, 24 hours a day, 7 days a week.

A. Injured Information:

 +
Time *
Gender *

B. Witnesses (attach signed statements)




C. Describe Accident/Injury (Include part of the body injured)

D.How did Accident/Injury Occur?

Police Report Filed? *

E. First Aid

Was first aid given? *

F. Action Taken

After the incident did the injured: *

G. Parent/Guardian Notification

Were parents/guardians notified? *

H. Equipment 

Was any equipment or object connected with this incident? *

I. Behavior

Did any behavior or activity by injured contribute to the incident/injury? *

J. Other contributing Factors? (Please list)

Please list them
+-

K. Prevention 

How could this incident have been prevented?            
+-

Electronic Signature

Published September 17th, 2019    

* Please Note: Once you submit this form, you'll have the option to print the form contents on the following page.
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