PLEASE SCROLL DOWN TO COMPLETE AN INCIDENT REPORT FORM

A Disabled Sports USA incident report form must be completed by chapters participating in the DSUSA insurance program to document any unexpected occurrence (injury, sickness, assault, etc.) regardless of whether or not medical attention was required. All appropriate staff and volunteers should be properly trained on this process and the forms should be available at all activity sites. The incident report form must be submitted via the electronic incident reporting form below or by completing a copy of the form FOUND HERE and emailing it to ccollins@dsusa.org. A sample of a properly detailed/completed incident report form can be found below.

Sample Incident Report – No Injury

Sample Incident Report – Major Injury or Illness

Below are the procedures for ensuring proper incident reporting:

  • Complete, in detail, all areas of the report form
  • Provide sufficient details to ensure that anyone who did not witness the incident will be able to understand exactly what occurred
    • Keep all narratives to known facts. Do not speculate on how the injury occurred or  injuries that have not been verified by a trained medical professional (i.e. “kayak fell on Timmy” vs. “kayak fell on Timmy because the last person may not have properly secured it” or “Susie complained of pain in her knee” vs. “Susie sprained her knee”)
    • Use personal names when detailing the incident, avoid the use of pronouns (he, she, they, we)
    • When multiple witnesses viewed the incident, each witness shall complete a separate Incident Report Form to help ensure all details are captured
    • When needed, attach additional pages to completely detail the incident
  • When available, attach all relevant documentation by treatment providers (i.e. ski patrol, lifeguard, paramedic, EMT, etc.)

The completed incident report form along with the Disabled Sports USA Waiver and Release Form must be submitted within 48 hours of the incident. Questions? Phone 301-217-9841 or e-mail ccollins@dsusa.org

 

Chapter Information

Injured Person Information

Please be as specific as possible. If none, please type "N/A"

Parent/Legal Guardian Information (If Injured Person is a Minor or Legally Incapacitated)

Injury Information

Please choose all that apply
Please choose all that apply

Incident Information

Please be as descriptive as possible and include all relevant information, including: Who was involved (please provide names and roles)? Where were they? What Happened? What was the sequence of events?

Response to Incident

i.e. Ski Patrol, EMT

Witness & Reporter Information

Please upload a copy of the individual's properly signed waiver & release