Incident Report Form

Please complete the following form in order to report an injury to a guest, volunteer or staff member. Multiple witnesses may complete this form. It is important to remember the following:

Report all incidents promptly (within 48 hours), regardless of how trivial they may seem. If the injury ends up being more serious, we will require initial documentation of the injury.
Treat the injured person with courtesy and sympathy, but do not admit liability or make any commitments.
Do not attempt to render first aid, except to make the injured person as comfortable as possible.
If the person is rendered unconscious or requires immediate medical attention, call 911 immediately.
Get the names and addresses of all witnesses. Do this in a way that will not magnify the situation.
Do not discuss the accident with anyone outside RMA, unless officially required.

When an accident occurs, get full details and enter them on this form. Use the completed form as the basis to report the accident the RMA office by giving them all the information.

Incident Report Form

Personal Information
Your Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Relation to RMA
Name of Injured Person*
First Last
Address of Injured Person (if known)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name of Other Witness (if applicable)
First Last
Phone of Other Witness (If applicable)
Incident Information
Date of Incident*
Date Format: MM slash DD slash YYYY
Location of Incident
Description of How Incident Occurred
Probable Cause of Incident
Weather Conditions at Time of Incident
Did Injured Person Continue in the Activity After the Incident?
Was First Aid Given?
Who Administered First Aid?
Did Injured Person go to Hospital?
Name of Hospital (if known)
Method of Transportation (if known)
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Incident Report Form

Incident Report Form

Personal Information

Incident Information

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