Incident Report

To be completed by Academy Manager or staff member that witnessed incident. This report is to identify any incident that has occurred with an employee, student, parent, spectator, guest student and/or any such individuals(s) while at the academy, event, tournament, testing and/or an activity at CLMA.

Date of Incident(Required)

Approximate time of incident(Required)

Academy Director

First Last

Instructor on the floor at time of incident

First Last

Location of Incident(Required)

Other Location(Required)

Other Location Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Person Injured(Required)

First Last

Phone(Required)

Rank of injured student.(Required)

Incident Description(Required)

Please be as detailed as possible and list all persons involved.

Witness

First Last

Phone

Witness

First Last

Phone

Comments by persons and or parents involved(Required)

Please check one(Required)

If a student, what gear was worn?(Required)

Was medical or other assistance needed?(Required)

Describe Assistance Given(Required)

Please be detailed and include injured body part(s), what type of care given, was an ambulance needed, etc?

ATA Dues Up to Date(Required)

No, dues are not up to date(Required)

If not, please explain why they were permitted to take class

Staff member submitting form:(Required)

First Last

Date Submitted(Required)

6788

Incident Report

Incident Report

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