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Incident Report

List all participants involved in the “additional participants” field.

A separate form should be submitted for each participant involved in an incident.

Participant's Name

Include additional participants immediately below

First Name

Last Name

additional participants

Parent's Name

Include additional parents immediately below

First Name

Last Name

additional parents

Parent's Contact Number

(###)

###

####

Parent Notified of Incident

Instructor's Name

Include additional instructors immediately below

First Name

Last Name

additional instructors

Date of Incident

YYYY

Time of Incident

Hour

Minute

Second

Nature of Incident

Description of Incident

Description of Action Taken

First aid? Corrective Actions? Special Instructions?

Follow Up

For example, were medical services required?

Other Notes

This form is to be completed for all child and staff incidents, accidents, injuries, and illnesses that happen during PSS sessions. The PSS Supervisor is responsible for ensuring appropriate signatures. A copy of this report must go in the Participant’s file. Please inform all appropriate staff of the incident and actions taken.

Incident Report

List all participants involved in the “additional participants” field.

A separate form should be submitted for each participant involved in an incident.

Pacific Skate School

818.416.1295

Pacificskateschool@gmail.com