Incident Report

What is the name of the injured person? *

First Name

Last Name

What is the injured persons contact number? *

Country

(###)

###

####

What is the name of the person completing this report? *

First Name

Last Name

What is the phone number of the person completing this report? *

Country

(###)

###

####

What was the date of the incident? *

MM

DD

YYYY

What time (roughly) did the incident occur? *

Hour

Minute

Second

AM PM

On a scale of 1 to 10, 1 being minor and 10 being major, please advise the severity of the injury *

1

2

3

4

5

6

7

8

9

10

Please select the type of injury that occurred *

Cut/Laceration

Bruise

Muscular

Dislocation

Fracture

Electrocution

Burn

Animal Bite

Other

Where on the body did the injury occur? *

Head

Face

Eyes

Arms/Shoulders

Hands

Torso

Waist/Hips/Groin

Legs

Feet