| Date of Incident | Time of Incident: | Location in Park: | Weather Conditions: | First | Last | Age: | Grade/Class: | Parent/Guardian Contacted Y/N: | First | Last | Incident Description | What Happened: | Witnesses: | Injury Details | Injured Body Part(s) | Type of Injury: | Detail Other | Medical Attention Required | Choices | Details: | follow-up | Reported By | Name: | Position: | Date | Park Lead Name: | Date |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Swings | cloudy, dry, cool | John | Doe | 7 | 2 | y | Betsy | Doe | Jumped out of swing while in the air, complained of right ankle hurting | Joe, Bill, & Mary | ankle |
|
| none | none | Bill Smith | section mgr | This is a test of this form by Roger. ONLY A TEST | |||||||||
| Mega Slide | Sunny | Test | test | 12 | 7 | N | test | test | Hit wall while sliding. | Michelle | foot |
|
| test | none | Michelle | FunPark Staff | Angela Mullin | |||||||||
| 10/24/2025 | 03:30 PM | Mega slide | cloudy, dry, cool | John | Doe | 12 | 5 | y | Jane | Doe | Went down head first. Scrubbed his face in the sand at the bottom of the slide | Betty | face |
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| none | none | Albert Pear | play ground manager | 10/24/2025 | This is a test of this form by Roger. ONLY A TEST | 10/28/2025 | |||||
| 11/07/2025 | 01:25 PM | Corn Pit | Sunny | Emmett | Buckner | 9 | 3 | Y | Ann | Austin | Corn got stuck in child's ear. | Sarah, Peyton, and Mattie | Ear |
| Mom's number, 803-622-0225 |
| After failed attempt, it was recommended for the child be taken to the doctor for further assistance. | None | Tiffany Mullen | Silo/Medic | 11/07/2025 | Angela Mullen | 11/07/2025 | ||||
| 11/02/2025 | 11:15 AM | Bounce Pillow | Clear | Carter | Cherry | 2.5 | 0 | Y | Robert | Cherry | The father Robert Cherry said he did not see the incident happen, but he assumes that his son got double bounced on the pillow and hyperextended his left knee. Phone# (248) 925-6526 | None | Left knee |
|
| We gave an ice pack for the knee. The father said that he is putting some weight on it, but will be taking him to urgent care to have it checked out. | Not sure father‘s phone number is listed | Sherri Davis | Silo Worker | 11/02/2025 | Sarah | 11/02/2025 | |||||
| Date of Incident | Time of Incident: | Location in Park: | Weather Conditions: | First | Last | Age: | Grade/Class: | Parent/Guardian Contacted Y/N: | First | Last | Incident Description | What Happened: | Witnesses: | Injury Details | Injured Body Part(s) | Type of Injury: | Detail Other | Medical Attention Required | Choices | Details: | follow-up | Reported By | Name: | Position: | Date | Park Lead Name: | Date |
