WSU 4-H Incident Report Form

Washington State University Extension 4-H Incident Report Form

Please report injuries directly to your Extension office within 48 hours. Submit this form to the county 4-H Extension Office within seven (7) days of the incident. Complete one form for each person involved. Also include any photographs, news clips, police reports, etc.

WSU 4-H Incident Report Form

Washington State University Extension 4-H Incident Report Form

EVENT INFORMATION

PERSON INVOLVED IN INCIDENT

DATE AND TIME OF INCIDENT

INITIAL REPORTING

Witness #1

Witness #2

Witness #3

DESCRIPTION OF INCIDENT

Signatures: Person(s) Completing All or Part of the Report:

4-H Faculty and/or Staff