For almost a year, we’ve had no accidents or unusual incidences at The Special Gathering of Indian River.  However, this week I had to fill out two unusual incident reports.  Here is the information you will need to process an unusual incident.  It is important that you record from your point of view what happened.  This could be a behavior, illness or accident.  This UIR was adapted from one of the leading companies in the US and is what they use.

The title we use is Incident/Accident Report.  Here is the information needed.

Member(s) Name:  (More than one person could be involved.)

Special Gathering Program:  (For us, this is the city location.)

Type of occurrence:  (Below this are the categories.  I am limited in formatting but these are indented.)



Accident:  (The majority of our reports are for accidents.)

Other (specify)

Date of incident:



Describe Incident/Accident:  (Give brief explanation of what happened.)

Previous Infractions:

Illustrate Position of Injury, if any:  (There are two drawings included.  One of the front of a person; the other of the back of a person.  You will mark the place(s) of the injury on the pictures.)

Immediate Action Taken:

Recommendations for Corrective Action:

Additional Information or Follow-Up:


Where taken or sent:

Transportation used:

Time of Departure:


Family Name:

Time of notification:

Physician Name:


Person completing form:

Date and Corrective Action Taken:

(This statement is included.)  All accident and abuse reports must be submitted to the executive director within twenty-four (24) hours of the occurrence.