First Report of Injury, Accident, or Incident – Customer Form

The form should be filled out by the person who sustained the incident/accident/injury on Ken-Caryl Ranch property, unless the person is a minor under 18 years of age. If you were just a witness to the incident/accident/injury, please instead fill out the Incident Report – Witness Form.

First Report of Injury, Accident, or Incident – Customer Form

"*" indicates required fields

This form reports an (check all that apply):

Incident

Accident

Injury

Name of Person Filling Out Form*

The form should be filled out by the person who sustained the incident/accident/injury unless the person is a minor under 18 years of age.

First Last

Street Address*

Phone*

Email*

Name of Injured Person (if different from person filling out form)

First Last

Describe the incident in detail, including how it occurred, nature of injury, body part(s) affected.*

Where did the incident occur? Include name of class/program/event if applicable.*

Was any equipment involved?*

Why did the incident/accident/injury occur?

Participating in an unsafe act

Failure to obey safety rules

Defective facility/equipment

Personal factors (aggression, etc.)

Lack of knowledge/skill

Intoxication or drug abuse

Other

Date of Incident/Accident/Injury*

Month

Day

Year

Time of Incident/Accident/Injury*

Hours

:

Minutes

AM PM AM/PM

Name(s) of Witness(es):*

Was first aid given?*

Yes

No

If first aid was given, by whom? Also describe what was done.

Name and address of treating physician (if none write "none")*

Was there any third-party responsibility? If yes, describe.*

Was there any property damage? If yes, describe.*

Guest Comments (if any)

Customer Signature*

This is a true correct statement of how this incident/accident/injury occured and the extent of the injury.

Δ