EmailMe Form - AHG Incident Report Form

Troop Number *

(For example: OH0001)

Does this incident involve any of the following? Please check all that apply.

A breach of confidentiality of medical records

Any threat of legal action or demand for payment which would cause a loss

Behavior of a Girl, Adult Member, facility personnel, or other individual that is concerning or not adhering to AHG's Health and Safety Policies and Guidelines

Incident/Occurrence of a missing AHG Member

Incident/Occurrence of an encounter with a suspicious or seemingly dangerous stranger

Injury or illness resulting in hospitalization

Injury/illness requiring emergency medical care

Loss of AHG records (through theft, natural disaster, etc.)

Removal of a Girl Member from a leadership position

Suspicion of abuse (in addition to required reporting to state and/or local authorities)

Use of a controlled substance by an AHG Member during a meeting, trip, event or activity

Name of location/facility

Location/facility Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Specific location of incident

(For example: chapel, campfire, playground, pool, tent, etc.)

Name of person(s) injured or involved in incident.

First Last

If this report is not about an injured person, please list the person most directly impacted by the incident. There is space below for indicating others who were present at the time of the incident.

Parent/Guardian Name (if the person is under the age of 18)

First Last

Parent/Guardian Phone Number

Parent/Guardian Email

Incident Date & Time *

MM / DD / YYYY HH : MM AM/PM

Is the person male or female?

Female

Male

Age of Injured Person

AHG Registration Status of Person

Describe what happened.

Describe the person's condition and any first aid that was given.

If you would like to upload additional documentation, please do so here.

Was two-deep leadership present?

Yes

No

Was there blood or bodily fluid exposure?

Yes

No

Was further medical attention sought?

Yes

No

Was the parent/guardian/emergency contact notified?

Yes

No

Were the authorities (police/fire department) notified?

Yes

No

Who was contacted and what was the outcome?

If the person left the site, with whom did they leave?

Please list any witnesses and if they were AHG Staff, facility staff, a Registered Adult Member or Girl Member. Your list might also include anyone present during the incident.

First and last name of the person filing this incident report.

First Last

Email Address of person filling out this incident report.

A copy of this form will be emailed to you.

Was there any follow up contact?

Yes

No

Additional Notes