EmailMe Form - AHG Incident Report Form

Troop Number *

(For example: OH0001)

Does this incident involve any of the following? Please check all that apply. *

Behavior of a Girl Member that violates the AHG Oath, Creed and/or the Troop’s behavior agreement that resulted in substantial physical, emotional and/or phycological consequence.

Behavior of an Adult Member or other individual that violates AHG’s Health and Safety Policies and Guidelines.

Critical illness and/or injury resulting in emergency intervention and/or hospitalization.

Loss of records including, but not limited to, medical records.

Lost and/or missing AHG Member.

Suspicion of abuse* or grooming behavior (*must also report to state and/or local authorities consistent with state law).

Threat of legal action or demand that may cause a loss.

Use of a substance, whether prescribed or otherwise, and/or recreational alcohol, by an AHG Member, that may alter or impair function.

Name of location

Location address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Specific location of incident

(For example: chapel, campfire, playground, pool, tent, etc.)

Name of person(s) involved in, or associated with the incident.

First, Last Name(s)

Parent/Guardian Name

First Last

Parent/Guardian Phone Number

Parent/Guardian Email

Incident Date & Time *

MM / DD / YYYY HH : MM AM/PM

Male or Female

Female

Male

Age/ Level

AHG Registration Status of Person

Describe what happened. *

Describe the person's condition and any first aid that was given.

If you would like to upload additional documentation, please do so here.

Was two-deep leadership present?

Yes

No

Was there blood or bodily fluid exposure?

Yes

No

Was further medical attention sought?

Yes

No

Was the parent/guardian/emergency contact notified?

Yes

No

Were the authorities (police/fire department) notified?

Yes

No

Who was contacted and what was the outcome?

If the person left the site, with whom did they leave?

Please list any witnesses if applicable

First and last name of the person filing this incident report.

First Last

Email Address of person filling out this incident report.

A copy of this form will be emailed to you.

Was there any follow up contact?

Yes

No

Additional Notes