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2. Instructions

   FILL IN ALL BLANKS.  If a blank does not apply to your accident, injury, or illness, then write “N/A” in the blank.  

4. First Name*
5. Last Name*
7. Age*
8. Sex*

   1. Male

   1. Female
10. Address*
11. Phone Number*
13. City*
14. State/Zip*
16. Parent or Guardian Contact Information:
18. First Name*
19. Last Name
21. Age*
22. Sex*

    1. Male

    1. Female
24. Address*
25. Phone Number*
27. City*
28. State/Zip*
30. Details of the incident:
32. Date of incident:*
33. Time of incident:*
34. AM/PM*

    1. AM
    2. PM
36. Location of incident:*
38. Specific description of the exact location at this address (i.e. sidewalk on east side of parking lot):*
40. Written description of the incident (in the citizen's own words):*
44. Witness (or employee) statement *
46. Witness Name:*
47. Witness Phone:*
49. Address:*
53. Witness (or employee) statement:*
55. Witness Name:*
56. Witness Phone:*
58. Address:*
60. Did Police of Emergency personnel respond?*

    1. Yes

    1. No
62. Responding Agency Name and Case Number:*
64. Attach the following documents, if relevant and available: Photos, signed waivers, quote/estimate, medical bills, receipts, posted warning signs, maintenance records/work orders on incident location:
66. Attachment 1

    Optional

    
    

67. Attachment 2

    Optional

    
    

68. Attachment 3

    Optional

    
    

69. Attachment 4

    Optional

    
    

71. Attachment 5

    Optional

72. Attachment 6

    Optional

73. Attachment 7

    Optional 

74. Attachment 8

    Optional

76. Other information:
78. Citizen's typed signature: *
79. Date:*
Leave This Blank:


81. 1. Receive an email copy of this form.
82. Email address

    This field is not part of the form submission.

83. Submit

* indicates a required field