Name of Injured:*

Age:*

Gender:*

M

F

Phone Number:*

Street Address:*

City:*

State:*

Zip Code:*

Place of Occurrence:*

Date of Injury:*

Time of Injury:*

Person Reporting Injury:*

Phone Number:

How did the accident occur? Ask the injured person to explain in his or her own words:*

Describe the Injury:*

Explain the First Aid that was Given:*

Who Administered First Aid:*

Is this person currently Certified in First Aid and CPR?*

Yes

No

Was EMS Called?*

Yes

No

Time Called:

Time of Arrival:

Services Rendered by EMS:

Notification of Family Member (specify whom and time and method of information):*

Please give names and phone numbers of two witnesses:

Name:

Phone Number:

Name:

Phone Number:

Name of person completing this report:

Date:

Street Address:*

City:*

State:*

Zip Code:*

Phone Number: *

Upon completion of this report, if it is an emergency, deliver it immediately to your supervisor or to the Division of Parks & Recreation Office, 118 North Market Street, Frederick, MD 21701. Also, click submit below.

If it is not an emergency, just click submit below.