ARC Client Incident Report HTML  Vers 1.0
Home Street Address:
City: State: Zip:
Home phone: Cell phone:
Birthdate (mm/dd/yyyy): Occupation or N/A:
Gender: Marital Status :
Name of person to Contact for Client in Emergency :
Emergency contact phone: Emergency contact Cell number:
Client Health Insurance Carrier:
Client Insurance Carrier Address :
Ins Policy Number :
Injury: Fatality: Local Law Enforcement notified (if necessary)
Date of Injury/Fatality(mm/dd/yyyy:) Date of Injury/Fatality:
Witness name: Witness Phone (cell?):
Description of (1) Injury/Fatality (type, part of body injured, what was the client doing, equipment involved, etc.) and (2) Initial Response to the Incident by the Red Cross:
Red Cross Internal Reporting – Reported to (mark all that apply):
Service Area              NHQ                Health Services          Staff Health Life Safety and Asset Protection
Did Incident Occur on the Premises of a:     Red Cross Owned Facility?     OR     Red Cross Operated Facility such as a Shelter?
Place of Incident (Name, Street address, City, State, Zip, County/Parrish):
If Shelter, Name of Chapter Operating Facility:
Red Cross Contact Name:
Contact Phone: Contact Cell Phone:
Contact E-mail Address:
Name of Physician: Telephone # :
Address of Physician:
Name of Hospital/Clinic:
Address of Hospital/Clinic:
Description of Treatment:
[HTML V 1.0 American Red Cross Gold Country Region February 2017]                                                                                                                                             ARC form April 2012