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:

Date of Accident/Injury: * +

Time *

a.m.

p.m.

Location (include complete address) *

City *

State *

Zip Code *

Name of Injured: *

Age: *

Gender *

Male

Female

Address *

City: *

State *

Zip Code *

Parent/Guardian Name: *

Phone (include area code): *

Parent/Guardian Email Address: *

B. Witnesses (attach signed statements)

Name

Phone:

Address

City:

State

Zip Code

Signed statement

Name

Phone:

Address

City:

State

Zip Code

Signed statement

Name

Phone:

Address

City:

State

Zip Code

Signed statement

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

Detailed Description: *

D.How did Accident/Injury Occur?

Detailed Description: *

Police Report Filed? *

Yes

If Yes, Police report number:

Police Department:

E. First Aid

Was first aid given? *

Yes

If Yes, to whom?

Where?

F. Action Taken

After the incident did the injured: *

continued activity

limited activity

went home

went to hospital

If taken to hospital, who took the injured?

Name of Hospital:

Hospital Address

City:

State

Zip Code

Name of Attending Physician

G. Parent/Guardian Notification

Were parents/guardians notified? *

Yes

If yes, how? ( writing, telephone, etc.)

Who notified parent/guardian?

H. Equipment

Was any equipment or object connected with this incident? *

Yes

If Yes, what?

How did it contribute?

I. Behavior

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

Yes

If yes, explain

J. Other contributing Factors? (Please list)

Please list them

K. Prevention

How could this incident have been prevented?

Electronic Signature

Electronic Signature By typing my name on this form, I am entering my "electronic signature" (as defined in The California Uniform Electronic Transactions Act 1633.1 - 1633.17) and certifying that I have read, fully understand and accept all terms of this agreement.

Please type your full name here: *

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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