Injury Incident Report Form

Hi there, please fill out and submit this form. If you have any questions, please contact Tiffany Trader at (208) 424-2635 or via email at ttrader@alscott.com. If you are an employee of the Idaho Outdoor Fieldhouse, please do not fill out this form, instead contact Layni at (208)424-3848 or via email at lculley@alscott.com.

Name of Person Reporting the Incident

Email of Person Reporting the Incident

Phone Number of Person Reporting the Incident

Are you reporting the incident on your own behalf?

YesNo

Name of injured person involved in the incident.

Contact Information of the Injured Person

Date of the Incident

Approximate Time of Incident

Hour

Minutes

Location of Incident

Event Outside of the Idaho Outdoor Fieldhouse FacilityPool AreaLocker Room AreaConference Room/Gathering AreaOffice AreaEntry Way AreaClimbing Wall AreaBathroom AreaHallwayIdaho Outdoor Fieldhouse HousingSummit Building (HBOT)Basketball CourtFitness Area (weights, turf, treadmill area)Other

Other Location

Did anyone witness the incident?

YesNo

Provide name(s) of witness(es) to the incident and contact information (phone number and email address).

Specific Body Part InjuredNote the specific body part injured for example, the cut is next to my fingernail on my index finger of my right hand.

Incident DescriptionDescribe how the incident occurred in the sequence it happened using only facts and observations. Please refrain from over-simplifying or over-complicating your description of the event. Leave a brief description here. You may provide additional supporting documents on the next question.

File Upload

Please upload any statements, photos, information or other supporting documents. Supports up to a total of 20 MB file(s) and the upload is slow so please be patient.

What was the name of the event you were attending when the incident occurred?

What specific activity were you doing when the incident happened?

Any additional action taken?

No Medical Treatment	First Aid Provided on-site
Emergency Room	Urgent Care
Emergency Services Contacted	Other

Other Action Taken

How are you connected with the Idaho Outdoor Fieldhouse?

Mission43 MemberCAF MemberGuestBoard MemberPartner with Idaho Outdoor FieldhouseOther

Other connection

Contact Information