| Date of Incident | 10/24/2025 |
|---|---|
| Time of Incident: | 03:30 PM |
| Location in Park: | Mega slide |
| Weather Conditions: | cloudy, dry, cool |
| Injured Person Details | |
| Name: | John Doe |
| Age: | 12 |
| Grade/Class: | 5 |
| Parent/Guardian Contacted Y/N: | y |
| Name of Parent/Guardian Contacted: | Jane Doe |
| Incident Description | |
| What Happened: | Went down head first. Scrubbed his face in the sand at the bottom of the slide |
| Witnesses: | Betty |
| Injury Details | |
| Injured Body Part(s) | face |
| Type of Injury: |
|
| Detail Other | |
| Immediate Action Taken: | took child to office, cleaned the wound and applied some antibiotic cream keeping it out of his eyes |
| Medical Attention Required | |
| Choices |
|
| Details: | none |
| Follow-Up Action (If any): | |
| follow-up | none |
| Reported By | |
| Name: | Albert Pear |
| Position: | play ground manager |
| Date | 10/24/2025 |
| Signature: | Albert Pear |
| Administrator Review | |
| Park Lead Name: | This is a test of this form by Roger. ONLY A TEST |
| Date | 10/28/2025 |
