Colorado Recreation Company
10807 New Allegiance Dr. #480 Colorado Springs, CO 80921
Ph: (303) 845-1174 Fax: (303) 845-2046
ACCIDENT REPORT
TO BE COMPLETED IN ADDITION TO THE INCIDENT REPORT FORM FOR EACH PERSON
INJURED
LOCATION:_____________________________
DATE OF ACCIDENT:______________________
TIME OF ACCIDENT:______________________
INFORMATION OF PERSON INJURED IN ACCIDENT
NAME:__________________________________
PHONE:________________________________
ADDRESS: ______________________________
________________________________________
IF MINOR, PARENTS NAME(S):_________________________________________
AGE OR DOB:____________
LOCATION WHERE ACCIDENT OCCURRED:_________________________________
PHOTOS TAKEN? (YES) / (NO)
ACCIDENT REPORTED TO:______________________ DATE/TIME REPORTED:_________________
MEDICAL ATTENTION GIVEN:__________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
BODY PART INJURED/INVOLVED IN ACCIDENT:_________________________________________
NATURE OF INJURY (EX. BURN, CUT, BRUISE, STRAIN. ETC):_____________________________
CONTRIBUTING FACTORS TO ACCIDENT:______________________________________________
__________________________________________________________________________________
___________________________________________________________________________________
CRC MANAGER REPORTING INCIDENT
DATE
PLEASE SUBMIT ALL MEDICAL DOCUMENTS TO THE OFFICE IF APPLICABLE.