Incident Information Report
(Events or allegations of injury, illness, or property damage, including employment and issues with directors and ofcers)
Incident date: ___________________Time: __________________________
Reporting date: _________________Time: __________________________
Council/BSA location: ___________________________________________ ❏ Leader ❏ Parent ❏ Other: _____________________
Reporting person: ___________________________________________________________________________________________________
Location of incident: _________________________________________________________________________________________________
Specic area where incident occurred:
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Cause of incident:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Program/event/adventure code: ______________________________________________________________________________________
Did the incident occur while transporting to/from an activity? ❑ Yes ❑ No
Comments:
____________________________________________________________________________________________________________________
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Individuals Involved (Duplicate If Needed)
Name: ______________________________________________________________________________________________________________
First Middle Last
Address: ___________________________________________________________________________________________________________
City State Zip
Home phone: _______________________Cell phone: _________________________Work phone: ________________________________
DOB: _______________________________Age: _______Unit No.: _______________Council: ____________________________________
Scouting role: ______________________________________________________________________________________________________
Type of injury or property damage: ________________________Injured body part: ___________________________________________
Was medical treatment given at scene? ❑ Yes ❑ No Type:____________________________________________________________
Medical disposition (transported to hospital, etc.): ______________________________________________________________________
Return this completed form to your council’s designated user for entry into RiskConsole via MyBSA Incident Entry.