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Magpie Performers
Home
WHAT’S ON
THEATRE WORKSHOP
About Us
Contact Us
Support Us
Accident-Incident-Report Form
Full Name
Street Address
Apartment, suite, etc
City
ZIP / Postal code
2. THE INCIDENT
Date
Location
Describe the Incident:
INJURIES
Was Anyone Injured?
Yes
No
If yes, describe the injuries:
WITNESSES
Were there witnesses to the incident?
Yes
No
If yes, enter the witnesses’ names and contact info
POLICE / MEDICAL SERVICES
Police Notified?
Yes
No
If yes, was a report filed?
Yes
No
Was medical treatment provided?
Yes
No
Refused
If yes, where was medical treatment provided?
On site
Hospital
Other:
CAST BEHAVIOR REPORT
CAST BEHAVIOR REPORT
PERSON FILING REPORT
Signature:
Date
Print Name:
OFFICE USE ONLY
Report received by:
Text
Follow-up action taken:
Action Taken:
Date
Submit