ࡱ> '` `bjbj{P{P :: yddddLLL8X4AFhf6 # %`EbEbEbEbEbEbE$GhJEuY;~Y;Y;EddE@@@Y;dD8`E@Y;`E@@C@|D PòxVL;CDF0AFC,J<JDJD&-@26&&&EE=F&&&AFY;Y;Y;Y; LLdddddd File this report within 24 hours of an accident/incident that occurs during a Girl Scout activity. Fax (901-797-2183) or mail to: Girl Scouts Heart of the South P. O. Box 240246 Memphis, TN 38124-0246  Name  FORMTEXT       Phone: Home (  FORMTEXT       )  FORMTEXT       Work: (  FORMTEXT       )  FORMTEXT       Cell: (  FORMTEXT       )  FORMTEXT       Address  FORMTEXT       City  FORMTEXT       State  FORMTEXT       Zip  FORMTEXT       Tr. #  FORMTEXT       Age Level  FORMTEXT        FORMCHECKBOX  Adult  FORMCHECKBOX  Girl Age  FORMTEXT       Sex  FORMTEXT       Parent/Guardian (if minor)  FORMTEXT       Home # (  FORMTEXT       )  FORMTEXT       Work # (  FORMTEXT       )  FORMTEXT       Was parent notified?  FORMCHECKBOX  Yes  FORMCHECKBOX  No By Whom  FORMTEXT        Date  FORMTEXT       Time  FORMTEXT        FORMCHECKBOX  a.m.  FORMCHECKBOX  p.m. Location  FORMTEXT       Type of Activity  FORMTEXT       Describe what happened and injury: (Use the back of this form if necessary.)  FORMTEXT        Name  FORMTEXT       Phone (  FORMTEXT       )  FORMTEXT       Address  FORMTEXT       City  FORMTEXT       State  FORMTEXT       Zip  FORMTEXT       Name  FORMTEXT       Phone (  FORMTEXT       )  FORMTEXT       Address  FORMTEXT       City  FORMTEXT       State  FORMTEXT       Zip  FORMTEXT       Describe Care given by whom:  FORMTEXT       Care Describe care: (Use the back of this form if necessary.) Given  FORMTEXT        Physician s name  FORMTEXT       Location  FORMTEXT       Hospital  FORMTEXT       Location  FORMTEXT       Was person retained overnight in hospital?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Date released  FORMTEXT        Name  FORMTEXT       Phone (  FORMTEXT       )  FORMTEXT       Address  FORMTEXT       City  FORMTEXT       State  FORMTEXT       Zip  FORMTEXT       Position  FORMTEXT       Signature  FORMTEXT       Date  FORMTEXT       Office Use Claim form(s) sent to Date Claim submitted for payment to Date Please keep a copy of this form with you at all Girl Scout activities. These guidelines should be kept in your First-Aid Kit. In the case of a serious accident or fatality, please follow council emergency procedures included in the Leaders Information Manual. Incident reports should be completed for any accident, illness or inappropriate behavior that occurs on the site or during program event. It is used to supplement insurance information and to notify the council of an incident while awaiting insurance forms and doctors statements. This report should be completed and submitted to the council office within 24 hours following the incident. You may call the council and file an initial report by phone; a copy will then be mailed for your signature. A leader, activity director or counselor may fill in sections of the form that relate to their actions. On-site First Aider and Program Director should complete separate forms. 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Girl Scouts Heart of the South  Accident/Incident Report Guidelines  Regional Service Centers Columbus, MS  662-328-1930(FAX: 662-328-1220(321 7th Street North, Columbus, MS 39701(Mailing: P. O. Box 2492, Columbus, MS 39704 Corinth, MS  662-287-8321(FAX: 662-286-8142(718 Taylor Street, Corinth, MS 38834( Mailing:P. O. Box 1145, Corinth, MS 38835 Grenada, MS  662-226-0255 or 888-453-2034(FAX: 662-226-0258(2430 Sunset Drive Ste D, Grenada, MS 38901 Jackson, TN  731-668-1122(FAX: 731-661-0011(1007 Old Humboldt Road, Jackson, TN 38305 Memphis, TN  901-767-1440 or 800-727-8104(FAX: 901-797-2183(2715 Kirby Pkwy, Ste 1, Mphs, TN 38119(Mailing: PO Box 240246, Memphis, TN 38124 Tupelo, MS  662-844-7577 or 800-624-4185(FAX: 662-680-3164(1800 W. Main St., Tupelo, MS 38801(Mailing: P.O. Box 1087, Tupelo, MS 38802 Website: www.girlscoutshs.org Girl Scouts Heart of the South  Accident/Incident Report  Regional Service Centers Columbus, MS  662-328-1930(FAX: 662-328-1220(321 7th Street North, Columbus, MS 39701(Mailing: P. O. Box 2492, Columbus, MS 39704 Corinth, MS  662-287-8321(FAX: 662-286-8142(718 Taylor Street, Corinth, MS 38834( Mailing:P. O. Box 1145, Corinth, MS 38835 Grenada, MS  662-226-0255 or 888-453-2034(FAX: 662-226-0258(2430 Sunset Drive Ste D, Grenada, MS 38901 Jackson, TN  731-668-1122(FAX: 731-661-0011(1007 Old Humboldt Road, Jackson, TN 38305 Memphis, TN  901-767-1440 or 800-727-8104(FAX: 901-797-2183(2715 Kirby Pkwy, Ste 1, Mphs, TN 38119(Mailing: PO Box 240246, Memphis, TN 38124 Tupelo, MS  662-844-7577 or 800-624-4185(FAX: 662-680-3164(1800 W. Main St., Tupelo, MS 38801(Mailing: P.O. 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