Date of incident: _______________ Time: ________ AM/PM
Name of injured person:
Date of birth: ________________ Male ______ Female _______
School name: ______________________________________________
Type of injury:
Details of incident:
Injury requires physician/hospital visit? Yes ___ No _____
Name of physician/hospital:
Physician/hospital phone number:
Signature of injured party _______________________________________________
*No medical attention was desired and/or required.
Form must be forwarded to and reviewed by simulation center Director within 24 hours of incident.