Incident Report Form

WITHIN 24 HOURS of any incident:

Complete this report and upload the Annual Permission Form or Girl Health History Form for Council Programs using the upload tab at the bottom of this form or email to Customer Care. or mail: ATTN Membership Manager, Girl Scouts of Hawai`i, 410 Atkinson Drive, Suite 2E1, Box 3, Honolulu, HI 96814.
Send a duplicate of all documents to your Service Unit Manager.

For COVID-19 Incidents please include the roster for all Adults and Youths in attendance. Troop & SU events, submit copies of the COVID-19 Waivers for all attendees to Customer Care.

This form is submitted to report:

Injury incident

Non-injury incident

Covid-19 Incident

Report Contact Information

Enter the full name of the person reporting this incident:

Role
Email
Phone Number

(if applicable) Full name of the Adult In Charge of this event

Role
Email
Phone Number

Enter the full name of the person affected by this incident (submit one form per incident and submit additonal details to customercare@gshawaii.org.)

Age
*
Troop Number
*
Phone Number
*

Address of person injured Address/City/ST/Zip

Parent / Caregiver

Relationship
*
Email
*
Phone Number
*

Method of Notification
*

phone, in-person, other
Date Notified
*
Time
*

Incident Location
*
Incident Date
*
Incident Time
*

Injury/Incident Details

Circumstances

Injury/Incident

Witness 1 Name

Witness 1 Relationship
*
Email
*
Phone
*

Witness 2 Name

Witness 2 Relationship
*
Email
*
Phone
*

Witness 3 Name

Witness 3 Relationship
*
Email
*
Phone
*

Treatment

On site treatment (if any)

Off site treatment (if any)

Health Care Professional/Doctor Full Name

Hospital/Office
Email
Phone

Health Care Office/Hospital Address/City/ST/Zip

Upload additional information and forms

Upload a document with additional information if more space is needed

Report Property Damage Information

(if applicable)

In the event of property damage complete the property damage report section.

Damaged Property (if any)

Contact name and number damage reported to:

Property Owner Name
Property Owner Phone
Email

Propery Address/City/ST/Zip

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Follow the Emergency Contact Card Information for detailed instructions of when to report to Council and whom to contact.

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