VDFP Accident Report Form

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Accident Report Form

This report must be submitted for each student requiring first aid or medical attention during any training activity conducted by the Virginia Department of Fire Programs.

This report must be submitted for each person requiring first aid or medical attention during any training activity conducted by the Virginia Department of Fire Programs. It must be completed by the instructors and forwarded to the Division Chief in the area in which the accident occurred within five (5) days of the accident. The Area Manager will conduct an investigation and forward findings to the Director of Training within five (5) days of receiving this form. Should it appear that the injured will require hospital admission and/or loss from work, or the accident results in a suspected or known fatality, the instructor(s) will immediately contact a Virginia Department of Fire Programs Division Chief or the Director of Operations who will initiate a preliminary investigation. A detailed report will be prepared by the Division Chief, in cooperation with the instructor(s), and forwarded to the Director of Operations within five (5) days.
School Number*
FDID*
Department Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Location of Training*
Title of Training Course*
Injured Person Information
Full Name of Injured Person*
First Last
Firefighter Type*
- Career
- Volunteer
Date of Birth*
Age*
Please enter a value between 1 and 100.
Height
Weight
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Accident Information
Date of Accident*
Day of Week*
Time (HH= 01-12 MM= 00-59)*

: HH

MM
Did this occur during Live Fire Training?*
- Yes
- No
Type/Extent of Injuries*
(*Please type the description)
First Aid / Medical Attention Rendered*
(*Please type the description)
Transported to emergency department or other medical facility*
- Yes
- No
Attending Physician
First Last
Physician Phone
Hospital
Hospital Phone
Instructor(s)*
Witness(es)*
Other Pertinent Factors (Weather, etc.)*
Describe how the incident occurred*
VDFP Staff Contacted*
First Last
Date Contacted*
Time Contacted (HH= 01-12 MM= 00-59)*

: HH

MM
Family or Dept. Contact Notified*
Date Contacted*
Time Contacted (HH= 01-12 MM= 00-59)*

: HH

MM
Report Submitted by
Submitter Name*
First Last
Submitter Email Address*
Instructor Number*
Submitter Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Work Phone*
Date Written Report Submitted*
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Accident Report Form

Injured Person Information

Accident Information

Report Submitted by