Appalachia Service Project

Appalachia Service Project Surveys

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Appalachia Service Project

Incident Report Form

Are you reporting: *

Illness
Infectious Disease
Injury
Auto Accident
Harassment
Unsafe Work Environment (Pulled off a project)
Other

If other, please specify: *

Date of Incident (mm/dd/yyyy) *

Time of Incident *

County Name: *

Center Email *

Name of Staffer Reporting the Incident: *

First

Last

Name of Affected Person (or driver if auto related): *

First

Last

Which best describes the role of the affected person? *

Youth Volunteer (under 18)
Adult Volunteer (over 18)
Staff Member
Homeowner
Community Member
Other

Phone Number of Affected Person: *

Email of affected person

Email

Confirm Email

Is the individual under the age of 18 and/or participating as a "youth"? *

Yes
No

Name of Parent or Guardian (if under the age of 18) *

First

Last

Phone Number Parent or Guardian (if under the age of 18) *

Nature of Auto Incident *

Single Vehicle Accident
Multi-Vehicle Accident
Mechanical Trouble
Other

If other, please specify: *

Year/Make/Model of vehicle being driven (or name of ASP vehicle): *

Please provide a description of the nature and extent of the incident? *

List names and contact information for any witnesses:

Give details of how and precisely where (address of worksite, street names if in transit, at center, etc.) the incident took place. Describe what activity was taking place at the time of incident: *

What part(s) of the body were injured/ill? Be specific (ring finger on left hand, hit head near right temple, etc): *

Did the injured/ill person go to the hospital or urgent care? If so, tell us the outcome. (stitches, medicine, etc.) *

If so, list the name and address of where they were seen.

Was the hospital/urgent care visit: *

Out patient (released the same day)
Required overnight(s) stay
No hospital visit
Other

If other, please explain:

Please check the boxes below of any additional services that have been contacted:

Police
Ambulance
None
Other

If other, please specify:

What happened to the injured/affected person after the incident was done and treatment administered? (ie was able to carry on with activity, went home, etc.) *

Is there anything you can think of that could have been done to prevent this incident? *

Any other information you would like to share?

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