FARM Training Center Incident Report

    Person submitting the report:

    It is extremely important that you fill in this form COMPLETELY!

    The information contained within all of the pages that make up this document is CONFIDENTIAL and PRIVILEGED. Said information is intended solely for the use of the individual to whom it is directed. If the recipient is a person / business other than those listed, you are hereby notified that any dissemination, copying, or other use of this communication is strictly prohibited.

    Victim and incident information:

    Victim Name

    Victim Phone

    Date of incident

    Sex of victim?

    Age of Victim?

    Check all items applicable:

    Describe the shooting / training experience of the victim; was he or she a student? Novice? Experienced?

    Describe the injuries suffered by the victim:

    Please provide all details regarding weather & environmental conditions (rain, mud, wind, etc.):

    Please provide details of any equipment failure:

    Please describe any rescue or emergency procedures used and first aid given:

    Please list any other emergency personnel / Agencies that attended:

    Narrative Report: Describe the accident and the events leading up to it with your best overview, including the roles of the participants. Give a complete account:

    Please describe your current status (i.e. Active Instructor, Student, LE etc.):

    Describe your personal participation in the incident (i.e. were you instructing the victim, a witness, called on to assist,

    Please list the names and phone numbers of all other participants, witnesses: