ACA Incident/Accident Report Form

Camp Name: Camp Sequoia
Address: 200 Seminary St, Pennsbrug PA 18073

Date of Report*

MM

DD

YYYY

Person Involved was a:*

Camper
Staff
Visitor

Sex of Person Involved:*

Male
Female

Name of Person Involved*

List the Primary Person Involved in Accident/Incident

First

Last

Name of Parent/Guardian (if minor was involved)

Phone Number of Parent/Guardian?

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Names of Witnesses*

Please list staff/campers involved in incident (add lines for each witness by hitting + symbol to the right)

Type of Incident*

Behavioral
Accident
Epidemic/Illness
Other (please describe)

Describe "other" selection:

Date of Incident*

MM

DD

YYYY

Time of Incident*

:
HH

MM

Describe the sequence of activity in detail including what the (injured) person was doing at the time:*

Where did the incident occur?*

Describe "other" selection:

Kriebel Floor:

Was injured participating in activity at time of injury/incident?*

Yes
No

If so, what activity?

Any equipment involved in injury/incident/accident?*

Yes
No

What equipment?

What could the injured have done to prevent injury?*

Emergency Procedures followed at time of incident/accident?*

(Please include who conducted the emergency procedures)

Submitted by:*

First

Last

Phone*

Please list the phone number of the submitter

Position*

Please list "other" position:

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ACA Incident/Accident Report Form