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2. 
3. The County of Powhatan

   Incident Report Form

5. This form is for internal use by the Parks and Recreation Department ONLY. It is intended solely for recreation staff, coaches, instructors, and volunteers.

   If you are a private citizen and your incident is not related to the Powhatan Parks and Recreation Department, please contact the Sheriff’s Office to file your report.

   If necessary, call 911 or the non-emergency number at 804-598-5656 for first responder assistance.  

7. Date of Report:*
   Date of Report:
8. Reported By:*
9. Title/Role:*
10. I am a:

    1. Staff
    2. Volunteer
    3. Coach
    4. Instructor
    5. Other
12. WARNING
    Parks Website

    STOP DO NOT USE THIS FORM
    
    This form is for P&R staff & volunteers only. Please contact P&R for more info.  

14. INCIDENT INFORMATION
16. Incident Type:
    -- Select One --Minor InjuryNear MissProperty DamageChemical ExposureSecurityEnvironmentalFireFatality
17. Date & Time of Incident:*
    Date & Time of Incident:

    Date & Time of Incident:
18. Program:*
20. Location:*
22. Specific Area of Location (if applicable):
24. City*
25. State*
26. Zip*
28. Incident Description
30. PERSON(S) INVOLVED
32. Person 1:*
33. Role:*
    -- Select One --ParticipantInstructorCoachUmpire/RefereeVolunteerCounty EmployeeParentOther (describe in description)
34. Phone Number:*
36. Person 2:
37. Role:
    -- Select One --ParticipantInstructorCoachUmpire/RefereeVolunteerCounty StaffParentOther
38. Phone Number:
40. WITNESSES
42. Witness 1:
43. Role
    -- Select One --ParticipantInstructorParentCoachUmpire/RefereeVolunteerCounty EmployeeBystander
44. Phone Number
46. Witness 2:
47. Role:
    -- Select One --ParticipantInstructorCoachUmpire/RefereeVolunteerParentBystander
48. Phone Number
50. Emergency Services Called?*

    1. Fire Department
    2. Sherriff's Department
    3. Non-Emergency Number
    4. EMS
    5. None
51. Police Report Filed?*

    1. Yes
    2. No
52. Name of First Responder:
53. Phone Number:
55. Transported to Hospital?*

    1. Yes
    2. No
56. Transported by Who?
57. Hospital Name:
59. Prepared By:*
60. Date:*
    Date:
62. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
64. Electronic Signature
Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit

* indicates a required field