ࡱ> ceb%` \bjbjNN 4`,,"""""""6###8#4*$6P- $$$$$%%%o,q,q,q,q,q,q,$\.h0,u"(%%((,""$$ -+*+*+*(d"$"$o,+*(o,+*+*""+*$$ @{DM@#{(X+** -0P-+*p1(p1+*p1"+*%vC&T+*&D&<%%%,,)d%%%P-((((666d$666666"""""" CAF 10 CAMP & YOUTH OUTREACH PROGRAM INCIDENT REPORT Texas A&M University-Kingsville Complete a report within 24 hours of any incident or accident involving a participant or where it was necessary to summon police officials because of health and safety concerns. Please obtain a statement from each witness involved indicating his/her recollection of the incident. Submit completed report to Dean of Students Office and Environmental Health and Safety Office. Section A: Camp / Youth Outreach Program: _______________________________________________________ Date of Incident: ____________________________________ Time of Incident: _________________ Location: __________________________________________________________________________ Description of Incident: ______________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Continue on a separate page if needed UPD Responded? % Yes % No Officer: _____________________ Case # _________________ Section B: Witnesses Name: _______________________________________ Phone # ____________________________ % Camp Participant % Camp Staff % Other __________________________________________________________ Address: _________________________________________________________________________ Street City State Zip Code Name: _______________________________________ Phone # ____________________________ % Camp Participant % Camp Staff % Other __________________________________________________________ Address: _________________________________________________________________________ Street City State Zip Code CAMPS & YOUTH OUTREACH GROUP INCIDENT REPORT PAGE 2 Section C. Involved PartyName: Birth date: % Male % FemaleAddress:Parent/Guardian:Phone #:Was parent notified? % Yes % NoNotified by:Section D. Complete Only If Injury or IllnessDescribe Nature of injury /illness: Injury occurred at: % Practice %Travel % Game % Other:Medical attention: % Yes % NoWho?Transported By:Is Injured / Ill person covered by any other health/accident insurance? % Yes % NoName of Policyholder(s) Insurance Company Policy Number Company Address   67WXqs % ( . > p q w 3 4 ? @ ǿǿǿǿǴǿuhFh1CJaJh1hFhoCJaJhohFhoCJaJhh5hMh5>*hP'Qhq hhP'Qho`hnhthFhtCJaJhth5CJaJhtht5CJaJhq5CJaJhChq5, 7WX 3 4 }}}{{{{{u{u@&gdn $@&a$gdnjkd$$Ifl$ t0644 la ytq $$@&Ifa$gdn \\ ? @ ; < 7 8  @&gdgd{gdgd1@&gdn ; < 7 8   vxhjltyqi^iq^yihFh{CJaJh{CJaJhCJaJh{h5ho`ho`5>*ho`h>*ho`h5>* h5>* h5hFhCJaJhCh15CJaJhCh{5CJaJh{h{CJaJh{hFh{CJaJh{hCJaJhFhCJaJh$vxjlI%&'B $Ifgd1$a$gd{gd1gd{@&gdgdHI$%&'/0ABC $&(:<prvxɓ}yncyyWyhEW%hM5CJaJh+hEW%CJaJh+h+CJaJhMh+hMCJaJhMhMCJaJhMCJaJhEW%h+5CJaJhEW%hEW%hEW%5CJaJh5CJaJhEW%5CJaJh+ h{5h{h{5hCJaJh{CJaJ h1hhhFh{CJaJ"BC $Ifgd1qkdT$$Ifl%d& t0644 lap yt{ & $Ifgd1qkd$$Ifl%d& t0644 lap yt{ &(: $Ifgd1qkdr$$Ifl%d& t0644 lap yt{ :<^p $Ifgd1qkd$$Ifl%d& t0644 lap yt{ prtvvmm $Ifgd1kd$$Ifl0%22 t0644 lapyt{ vxvmm $Ifgd1kd1$$Ifl0%22 t0644 lapyt{ vm $Ifgd1kd$$Ifl0%22 t0644 lapyt{ > $Ifgd1qkds$$Ifl%d& t0644 lap yt{   <>@bnprt$&(@BDڿһһһһڐ}yhMh+hqCJaJhqCJaJhMCJaJh+hEW%CJaJh h CJaJh]h]CJaJhEW%hCJaJh+h+CJaJhEW%CJaJh+hEW%hEW%5CJaJhEW%h+5CJaJh5CJaJ,>@ $Ifgd1qkd$$Ifl%d& t0644 lap yt{  $Ifgd1qkd$$Ifl%d& t0644 lap yt{  $Ifgd1qkd $$Ifl%d& t0644 lap yt{  $Ifgd1qkd$$Ifl%d& t0644 lap yt{  $Ifgd1qkd>$$Ifl%d& t0644 lap yt{ dn $Ifgd1qkd$$Ifl%d& t0644 lap yt{ nprvm $Ifgd1kd\$$Ifl0%22 t0644 lapyt{ rt $Ifgd1qkd$$Ifl%d& t0644 lap yt{ B $Ifgd1qkd $$Ifl%d& t0644 lap yt{ BD $Ifgd1qkd $$Ifl%d& t0644 lap yt{ Dx~TTTTTTTTTUU6UDUUUU0VcVnVVVVVVVnW|W}W\\\\\\\\\\\\\㺶瘣h1jh1U h1h hhhh] h]h h CJaJho` hh hMh5hMhM5hMhM5>*hhFh Uh1hqCJaJhq hqhq3TTTTTbUdUUUU0VV| &d P gd1gd1qkd $$Ifl%d& t0644 lap yt{ *If more than one person involved  add a separate page 2 for each person Section E: Supervisor of Activity: ________________________________ Phone # _______________________ Was he/she a witness to the injury? 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