Evergreen USA

To be completed by campground staff, not injured or involved person(s).

This form is intended for recording & reporting of all non-employee injuries/incidents, regardless of whether or not the injured person received medical treatment. If the injured person is an employee, a Workers Compensation Reporting form should be completed. (Workers Compensation Employee Reporting Form may be required, in your state, to be provided to the employee within 24 hours of any injury.)

Campground or R.V. Park Information

Name of Campground:

Street:

City:

State:

Zip:

Telephone Number:

Person to Contact:

Email Address:

Specific Information Related to Incident

Date of Incident:

MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day12345678910111213141516171819202122232425262728293031

Year200820092010

Date Incident Reported:

MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day12345678910111213141516171819202122232425262728293031

Year200820092010

Time Incident Occurred:

hour123456789101112

:

minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859

am

pm

Specific Location of Incident in Park:

Specific Information on Injured Person or Person Involved

Person's Name:

Age:

Sex:

Male

Female

Person's Address:

City:

State:

Zip:

If Minor, Name of Parent/Guardian:

Relationship:

Phone Number / Notations:

Description of Incident

Description of Incident:

Written By:

Medical Response

Check here if no one was injured:

No one was injured.

Was First Aid Provided at Scene?:

Yes

No

If Yes, By Whom:

Park Staff?:

Yes

No

Was the injured person taken for treatment?:

Yes

No

If No, was treatment recommended by park staff?:

Yes

No

If treated, where?:

Transported By:

Describe Injury & Treatment:

Witness Information (list both employee and non-employee witnesses)

Witness 1

Name:

Type:

Eye Witness

Second Hand

Relationship to Person:

Address:

City:

State:

Zip:

Phone # / Notation:

Witness 2

Name:

Type:

Eye Witness

Second Hand

Relationship to Person:

Address:

City:

State:

Zip:

Phone # / Notation:

Witness 3

Name:

Type:

Eye Witness

Second Hand

Relationship to Person:

Address:

City:

State:

Zip:

Phone # / Notation:

Notes: (See instruction block regarding evidence protection.)

Notes:

Report completed by:

Title:

Date:

MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day12345678910111213141516171819202122232425262728293031

Year20092010

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