Report Injury

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Report an Injury

Use this form to report injuries, illnesses, and incidents requiring medical attention beyond basic first aid. Suitable for situations occurring during Scouting activities or on council-owned properties

General Details

Incident Date(Required)

MM slash DD slash YYYY

Incident Time(Required)

Hours

Minutes

AM/PM

Report Date(Required)

MM slash DD slash YYYY

Date Reported to Council(Required)

MM slash DD slash YYYY

Reported By: Name(Required)

First & Last Name

Reported By: Primary Phone(Required)

Reported By: Secondary Phone

Reported By: Email(Required)

Reported By: Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Council/Scouting America Location(Required)

Location of Incident(Required)

Specific Area Where Incident Occurred

Incident Address

Street Address City State / Province / Region ZIP / Postal Code

Description of Incident (Clear, Concise, Complete Facts)(Required)

Was an Agency or Authority Notified?(Required)

Yes

Which One(s)?

Injury, Illness, or Damage Information

Claimant: Name(Required)

First & Last Name

Claimant: Primary Phone

Claimant: Secondary Phone

Claimant: Email

Claimant: Address

Street Address City State / Province / Region ZIP / Postal Code

Claimant: Date of Birth

MM slash DD slash YYYY

Claimant: Age

Claimant: General Classification (Cub Scout, Leader i.e.)(Required)

Claimant: Chartered Organization

Property Damage?(Required)

Yes

Describe:

Adventure, Program, or Event of Incident(Required)

Cause/Nature/Injury Detail(Required)

Was Medical Treatment Provided?(Required)

Yes

Describe (If applicable, please include if transported via ambulance or air):

Are Accident and Sickness Forms Provided or Filed?(Required)

Yes

Unknown

If Certificate of Insurance Has Been Provided, Please Describe:

If There is/was a Contract for the Event, Please Describe:

Did the Event Occur While Transporting to or from Activity/Event?(Required)

Yes

Vehicle Involved

Owner of Vehicle: Name

First & Last Name

VIN

Vehicle Make/Model/Year

License State

Driver of Vehicle: Name

First & Last Name

Driver of Vehicle: Address

Street Address City State / Province / Region ZIP / Postal Code

Driver of Vehicle: Primary Phone

Driver of Vehicle: Email

Description of Vehicle Damage

Weather Conditions

Witness to Event

Witness: Name(Required)

First & Last Name

Witness: Email

Witness: Primary Phone

Witness: Secondary Phone

Witness: Address

Street Address City State / Province / Region ZIP / Postal Code

Witness Type

Adult

Youth

Unknown

Do You Have Another Witness?

Yes

Additional Witness

Witness: Name(Required)

First & Last Name

Witness: Email

Witness: Primary Phone

Witness: Secondary Phone

Witness: Address

Street Address City State / Province / Region ZIP / Postal Code

Witness Type

Adult

Youth

Unknown

File Upload

Attachments such as photos and statements can be helpful when making a report of incident.

File

Max. file size: 2 GB.

10078 Reading Rd, Cincinnati, OH 45241
Call: (513) 577-7700 | Fax: (513) 577-7738

Helpful Links

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