Scouts Canada Incident Report Form

Scouts Canada Incident Report Form
Please submit an incident report for any behaviour or event that raises safety concerns (examples: injury, illness, behaviour inconsistent
with the Code of Conduct, property damage, and complaints). Any questions about this process should be sent to [email protected]
Incidents should be reported by:
1. If the incident is of a serious nature, immediately calling Scouts Canada at 1-800-339-6643.
Any questions about this process should be sent to [email protected]
2. For all incidents including those reported as in 1. above, complete this Incident Report Form and submit it to
Scouts Canada by email to [email protected] OR by FAX to 613-224-3571 OR by mail to Scouts Canada,
1345 Baseline Road, Ottawa, ON K2C 0A7 as soon as possible following the incident
3. Send or give a copy of the Incident Report to your local Council Office.
INFORMATION ON INJURED PERSON OR OWNER OF DAMAGED PROPERTY
Name:
Birthdate:
Address:
Phone numbers:
Home:
Work:
Complete this section
if this person is a
registered member.
Group:
Section:
Youth member
Adult member
Date of incident:
Place and nature of
activity:
Description of incident
and nature of injury or
property damage (see
notes * and ** below.)
Complete following if applicable:
Name of doctor consulted:
Telephone:
Name and address of hospital or clinic:
Witness Name:
Home Phone:
Work Phone:
Witness Name:
Home Phone:
Work Phone:
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Scouts.ca
INFORMATION ON THE GROUP
Name of Group:
Section:
Name of Leader in Charge:
Address:
Phone numbers:
Home:
Work:
Fax:
E-mail:
COMPLETE ONLY IF THIS INCIDENT WAS REPORTED TO POLICE
Police Station Name/Number:
Police Station Address:
Name and Phone Number of Officer in Charge:
REPORTING MEMBER’S INFORMATION
This report must be signed
by a currently registered
Scouting member or
a current employee of
Scouts Canada.
A copy of this report
should also be sent to your
local Council Office – see
instructions on top of
this form.
*
Full Name:
Position in Scouting:
Street:
City:
Province:
Postal Code:
Telephone (home):
Telephone (work):
Fax:
E-mail:
Signature:
Date:
If a vehicle was involved, please include name, address and telephone number of vehicle owner and of the vehicle driver,
if not the same.
** Submission of this report no later than 30 days from the incident date constitutes notice of a potential claim only. To
submit a claim, please attach to this form, or send under separate cover, original receipts and/or standard dental claim
forms which are available from your dentist. See BP & P, Forms Section 20000,
For National Office use only:
Forwarded to broker(s) on
Liability
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Indemnity