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2. Date and Time of Incident
   Date and Time of Incident

   Date and Time of Incident
4. Staff Member Completing Form
5. Date
   Date
7. Location of Incident / Injury
9. Involved in Incident
   -- Select One --ParticipantMemberStaffOther
11. First Name
12. Last Name
14. Address1
16. City
17. State
18. Zip
20. Cell Phone
21. Email Address
22. Age
23. Sex
25. Is the person involved a Silver Sneaker Member?

    1. Yes
    2. No
26. DOB
    DOB
28. Description of Incident / Injury
30. Description of how incident was resolved/treatment
32. Police Called*
    -- Select One --YesNo
33. Time Called
34. EMS Called
    -- Select One --YesNo
35. Time Called
37. Treatment rendered by
38. If a minor, parents notified at time of report?
    -- Select One --YesNo
39. Time Called
    Time Called
41. Signature

    Digital signature

43. Witness (If Applicable)
44. Date
    Date
46. First Name
47. Last Name
49. Address1
51. City
52. State
53. Zip
55. For Employee Injuries Only
57. Was Employee Seen by a doctor?

    1. Yes
    2. No
58. Did Employee report back to work?

    1. Yes
    2. No
59. Date Returned to work
    Date Returned to work
Leave This Blank:


61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit

* indicates a required field