Free Playground Accident Report Form Template

Playground Accident Report Form

Please fill out this form completely to report a playground accident.

Accident Details

Date and Time of Accident

    Location of Playground

      Description of Accident

        Injuries Sustained

          Injured Party Information

          Name

            Age

              Address

                Parent/Guardian Name (if applicable)

                  Phone number

                    Witness Information

                    Name

                      Phone number

                        Relation to Accident (if any)

                          • Witness

                          • Parent/Guardian

                          • Participant

                          • Playground Supervisor

                          Actions Taken

                          First Aid Administered

                          If yes, please describe

                            Emergency Services Contacted

                            Further Action Taken

                              Signature of Reporter

                              I confirm that the above information is accurate to the best of my knowledge.

                              Name:
                              Date:

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