Crew Incident Report

Crew Program Incident Report

This form should be filled out anytime a WisCorps employee or AmeriCorps Member sustains an injury that requires more than just basic first aid or might require professional medical services. When in doubt, fill it out!

Person Completing Injury Form(Required)

First Last

Participant's Name(Required)

First Last

Best Phone Number To Reach Participant?(Required)

Personal phone? Crew phone? Other?

Date of Injury(Required)

What day did the injury first take place?

Time of Injury(Required)

At approximately what time did the injury take place?

Injury Description(Required)

Describe Activities of Participant When Injury or Illness Occurred and What Tools, Objects, Chemicals, Etc. Were Involved.

What Happened to Cause This Injury or Illness?(Required)

(Describe How The Injury Occurred)

What Was The Injury or Illness?(Required)

(State the Part of Body Affected and How It Was Affected)

Injury Photo #1

Max. file size: 50 MB.

Injury Photo #2

Max. file size: 50 MB.

Did this injury occur because..

Substance abuse

Failure to use safety devices

Failure to obey rules

(check any that apply)

CAPTCHA

This field is for validation purposes and should be left unchanged.