Emergency – 402F
Accident Summary Report
Accompanied by:_________________________________________________
Last Name_______________________ First Name______________________ Name/Contact #__________________________
Address: _____________________________________________________________________
Phone(s): _____________________________________________________________________
Please indicate (H)home; (C)cell; (W)work
______________________________________________________________________________
Date of Birth Gender Approximate Height Approximate Weight
Witnessed by: __________________________________________________________________
Name_______________________________________Contact Telephone ________________________________
Description of Incident: __________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Describe accident victim’s clothes and shoes
Was accident victim carrying anything: Yes ______ No ______ If so, what________________
Were there children with the accident victim: Yes ______ No ______ Description:__________
______________________________________________________________________________
Date of Accident Place of Accident
______________________________________________________________________________
Injuries
Treated at Scene: Yes ______ No ______ By Whom:_________________________________
Ambulance Called: Yes ______ No ______ Left via Ambulance: Yes ______ No ______
Weather conditions: ____________________________________________________________
Interior conditions: (surface wet or dry)______________________________________________
Photos taken: Yes ______ No ______
Staff on duty at time of accident: ___________________________________________________
Employee Signature: ____________________________________________________________
Send completed form to Director’s Office, Downtown Library, 927 Felix Street.