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Incident Reporting Tool
(Events or allegations of injury, illness, or property damage, including employment and directors and ofcer’s issues)
General Incident Details
*Required Fields
*Incident Date: ________________________________ Incident Time (in 24-hour format): ______________________________________
*Report Date: _______________________________________________________________________________________________________
Date Reported to Council/BSA Location: ______________________________________________________________________________
Reported by Name: _________________________________________________________________________________________________
Reported by Primary Phone: ______________________________ Reported by Secondary Phone: _____________________________
Reported by Email: __________________________________________________________________________________________________
Reported by Address: _______________________________________________________________________________________________
Reported by City: _________________________________ Reported by State: __________ Reported by Zip Code: _______________
*Council/BSA Location: ______________________________ *Location of Incident: ___________________________________________
Specic area where incident occurred: ________________________________________________________________________________
Incident Address: ___________________________________________________________________________________________________
Incident City: _____________________________________ *Incident State: ______________ Incident Zip Code: ___________________
*Description of Incident (clear/concise/complete facts):
Was an Agency or Authority Notied? Yes No Whom: ____________________________________________________
Injury/Illness/Damage Information
*Claimant Name: ____________________________________________________________________________________________________
Claimant Address: __________________________________________________________________________________________________
Claimant City: ____________________________________ *Claimant State: _____________ Claimant Zip Code: __________________
Claimant Primary Phone: ___________________________ Claimant Secondary Phone: _______________________________________
Claimant Email: _____________________________________________________________________________________________________
Claimant Date of Birth: _________________________________________ Age of Claimant: _____________________________________
General Classication (Cub Scout/Registered Leader/etc.): _____________________________________________________________
Chartered Organization: _____________________________________________________________________________________________
Property Damage? Yes No Describe: __________________________________________________________________
Adventure/Program/Event: ___________________________________________________________________________________________
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People are best convinced by things they themselves discover. | Ben Franklin