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GSGLA Accident/Incident Report

Accident/Incident report forms are submitted when an incident or accident occurs.
For incidents occurring after hours,
"Emergency After Hours Call Card" (Pink Card).

Girl Scouts of Greater Los Angeles Emergency Phone # 1-877-423-4752

Please submit ONE report within 72 hours of the incident
Contact Information
Name of adult directing activity:*
First Last
Title:*
Phone:*
Email*
Enter Email Confirm Email
Service Unit*
Hidden
Troop/group Number:*
Troop/group Number:*
eSignature of adult directing activity:*
Incident Information
Date of Emergency:*
MM slash DD slash YYYY
Time am/pm:*
Date of report:*
MM slash DD slash YYYY
Did the incident take place on GSGLA property?*
- Yes
- No
Name/Address of GSGLA Property Incident Occurred:*
Name/Address of Location Incident Occurred:*
Was anyone injured?*
- Yes
- No
Incident Description:*
Describe in detail events leading to injury/incident and what you did. Were medical advice and/or emergency transport required?
Was this a GSGLA camp property?*
- Yes
- No
Which camp?*
Please describe:*
Were the police contacted?*
- Yes
- No
Was a police report filed?*
- Yes
- No
Were there any witnesses?*
- Yes
- No
Injury Information
How many people were injured?*
First Injured Person's Information
Name of Injured Person:*
First Last
Date of Birth:*
MM slash DD slash YYYY
Age:*
Phone Number:*
Email:*
Enter Email Confirm Email
Service Unit*
Troop Number:*
Complete Address:*
Street Address City State ZIP Code
Nature and extent of injury:*
Name of attending medical professional:*
First Last
Title of attending medical professional:*
Treatment given:*
Name of Hospital:*
City/Location:*
Hospital Phone:*
Second Injured Person's Information
Name of Injured Person:*
First Last
Date of Birth:*
MM slash DD slash YYYY
Age:*
Phone Number:*
Email:*
Enter Email Confirm Email
Service Unit*
Troop Number:*
Complete Address:*
Street Address City State ZIP Code
Nature and extent of injury:*
Name of attending medical professional:*
First Last
Title of attending medical professional:*
Treatment given:*
Name of Hospital:*
City/Location:*
Hospital Phone:*
Third Injured Person's Information
Name of Injured Person:*
First Last
Date of Birth:*
MM slash DD slash YYYY
Age:*
Phone Number:*
Email:*
Enter Email Confirm Email
Service Unit*
Troop Number:*
Complete Address:*
Street Address City State ZIP Code
Nature and extent of injury:*
Name of attending medical professional:*
First Last
Title of attending medical professional:*
Treatment given:*
Name of Hospital:*
City/Location:*
Hospital Phone:*
Fourth Injured Person's Information
Name of Injured Person:*
First Last
Date of Birth:*
MM slash DD slash YYYY
Age:*
Phone Number:*
Email:*
Enter Email Confirm Email
Service Unit*
Troop Number:*
Complete Address:*
Street Address City State ZIP Code
Nature and extent of injury:*
Name of attending medical professional:*
First Last
Title of attending medical professional:*
Treatment given:*
Name of Hospital:*
City/Location:*
Hospital Phone:*
Fifth Injured Person's Information
Name of Injured Person:*
First Last
Date of Birth:*
MM slash DD slash YYYY
Age:*
Phone Number:*
Email:*
Enter Email Confirm Email
Service Unit*
Troop Number:*
Complete Address:*
Street Address City State ZIP Code
Nature and extent of injury:*
Name of attending medical professional:*
First Last
Title of attending medical professional:*
Treatment given:*
Name of Hospital:*
City/Location:*
Hospital Phone:*
Additional injured parties:*
For injured persons in addition to the five listed above, please upload a document (pdf or word) containing the information above for each person.
Accepted file types: pdf, doc, Max. file size: 50 MB.
Witnesses:
How many witnesses?*
Name #1:*
First Last
Phone #1:*
Address #1:*
Street Address City State ZIP Code
Name #2:*
First Last
Phone #2:*
Address #2:*
Street Address City State ZIP Code
Name #3:*
First Last
Phone #3:*
Address #3:*
Street Address City State ZIP Code
Additional Information
Additional Information:
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