Section 1 — Incident Location

Location *

Incident occurred within Village of Lake Success municipal boundaries

Responsible Party

Section 2 — Injured Person / Property Owner

Full Name *

Date of Birth *

Sex * — M F Other

Phone *

Address *

Section 3 — Incident Details

Date of Incident *

Time of Incident *

Reported To *

Severity — Select — Minor Moderate Serious

Section 4 — Descriptions

What was the injured person doing at the time?

Describe the incident / injury *

Statement by injured person

Section 5 — Alleged Defect / Hazard

An alleged defect or hazard was involved in this incident

Prior notice of defect / hazard

Section 6 — First Aid

First aid was provided

First aid provided by

Description of first aid provided

Section 7 — Transport / Medical

Transported to *

Hospital / Doctor name

Section 8 — Witnesses

Witness names and contact information

Section 9 — Refusal of Care

Injured person refused care / treatment

By signing below, the injured party acknowledges they refused care and releases the Village of Lake Success from liability related to this refusal.

Printed name of refusing party

Signature of refusing party

Clear

Section 10 — Paramedic / EMS Waiver

Paramedic / EMS waiver was signed

Printed name

Signature

Clear

Section 11 — Reporting Staff Member

Your name *

Your signature *

Clear