Incident Report Form

Complete immediately following any incident. All incidents must be logged per program policy and insurance requirements.

If this is a life-threatening emergency, call 911 first. Complete this form as soon as the situation is stabilized. Retain a copy for the Hoop Vision incident log. Do not alter or destroy this record.

1 — Report Information

Report Date *

Report Time *

Report ID

Reported By (Staff Name) *

Staff Title / Role *

Staff Phone

2 — Incident Details

Date of Incident *

Time of Incident *

Location / Facility *

Program / Activity at Time of Incident *

Activity Specify (if Other)

Incident Type *

Severity *

Minor

Moderate

Serious

Critical / 911

Description of Incident *

3 — Person(s) Involved

Full Name *

Role

Date of Birth / Age

Parent / Guardian Name (if minor)

Parent / Guardian Phone

Body Part / Area Affected (if injury)

4 — Witnesses

Witness 1 Name

Witness 1 Phone

Witness 2 Name

Witness 2 Phone

5 — Response & Action Taken

Immediate Action Taken *

First aid administered on site 911 / EMS called Transported to hospital / urgent care Parent / guardian notified Participant / individual removed from activity Physician clearance required before return No immediate medical action required

Details of Response / Action Taken *

Was this a suspected concussion?

Yes No Unknown

Follow-Up Required / Pending

6 — Notifications Made

Program Director Notified?

Yes No

Date / Time Notified

Insurance Carrier Notification Required?

Yes No To Be Determined

Additional Notes / Comments

7 — Staff Certification

I certify that the information provided in this report is accurate and complete to the best of my knowledge, and that this report was completed promptly following the incident.

Staff Electronic Signature (type full name) *

Date *

Fields marked * are required | Retain a copy for the incident log.

CodePoint Capital LLC d/b/a Hoop Vision • Incident reports are confidential • dev@codepointcapital.com