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Incident / Notice of Injury Form
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What was the date of the incident or injury?
*
MM
/
DD
/
YYYY
What was the approximate time of the incident or injury?
*
Time
:
AM
PM
Where did the incident or injury take place?
*
Your answer
What is the full name of the person involved in the incident or injury?
*
Your answer
What is the approximate age of the person involved in the incident or injury?
Your answer
What is your street address of the person involved?
Your answer
In what city does the person involved live?
Your answer
In what state does the person live?
Your answer
What is the zip code?
Your answer
If the person involved is a minor, what is/are the name/names of the parents or guardians?
Your answer
Please give a full description of the injury or incident.
*
Your answer
If this was an injury, where was the person taken for treatment?
Your answer
What is the relationship of the person involved to Valley Grace?
Employee
Member
Regular Attender
Visitor
Volunteer
Other:
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If the incident or injury occurred on Valley Grace’s property, for what purpose was the injured on the premises?
Your answer
If the incident or injury occurred elsewhere, what connection did it have with Valley Grace’s operations or activities?
Your answer
Who was responsible for supervision at the time of the injury or incident?
Your answer
Does the injured have personal medical insurance?
Yes
No
Clear selection
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