 ARC Client Incident Report HTML Vers 1.0 |
| CLIENT INFORMATION |
| Name: |
| Home Street Address: |
| City:
State:
Zip:
|
| Home phone:
Cell phone:
|
| Birthdate (mm/dd/yyyy):
Occupation or N/A:
|
| Gender:
Marital Status :
|
| Name of person to Contact for Client in Emergency :
|
| Emergency contact phone:
Emergency contact Cell number:
|
| Client Health Insurance Carrier:
|
|
Client Insurance Carrier Address :
|
| Ins Policy Number :
|
|
| Injury:
Fatality:
Local Law Enforcement notified (if necessary)
|
| Date of Injury/Fatality(mm/dd/yyyy:)
Date of Injury/Fatality:
|
| Witness name:
Witness Phone (cell?):
|
Description of (1) Injury/Fatality (type, part of body injured, what was the client doing, equipment involved, etc.) and (2) Initial Response to the Incident by the Red Cross:
|
Red Cross Internal Reporting – Reported to (mark all that apply):
Service Area
NHQ
Health Services
Staff Health Life Safety and Asset Protection
|
INCIDENT LOCATION INFORMATION
|
| Did Incident Occur on the Premises of a:
Red Cross Owned Facility? OR
Red Cross Operated Facility such as a Shelter? |
| Place of Incident (Name, Street address, City, State, Zip, County/Parrish):
|
| If Shelter, Name of Chapter Operating Facility: |
| Red Cross Contact Name: |
| Contact Phone:
Contact Cell Phone: |
| Contact E-mail Address:
|
|
| Name of Physician:
Telephone # :
|
| Address of Physician:
|
| Name of Hospital/Clinic:
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| Address of Hospital/Clinic:
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Description of Treatment:
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