Incident Report Guidelines

1. At the time of incident:

Do not admit liability or fault to anyone at the scene of the incident
Encourage participant to seek medical attention if there is any possibility of injury
Mitigate the possibility of any further injury/damage to the best of your ability
Obtain witnesses' names and addresses
Take photographs of the area involved, if possible
Document all factors contributing to the loss

2. As soon as possible - but no later than 24 hours after arriving home - please complete the Incident Report.

3. After reporting a claim:

Do not discuss the events of the claim with any attorneys or claim personnel other than those representing Leukemia & Lymphoma Society
Consider ways to prevent a similar loss from occuring
If you have any questions, please contact Dee Dee Said at deedee.said@lls.org or Insurance@lls.org.

Incident Report

Please complete the information below, providing as much information as possible. When finished, click on submit to send to the LLS Risk Management Department.

Constituents Full Name (involved in incident): *

Phone Number: *

Home Address: *

City *

Date of Incident: * +

Approximate Time (HH:MM): *

Today's Date: * +

Campaign: *

Other: *

Did the incident occur at a group training or during an Event? *

Please describe how the incident occurred: *

Please describe the injury, illness or damages as a result of the incident: *

Please describe treatment given at the time of the incident: *

Was the injured person transported to a hospital? *

Name of Hospital: *

Were there any witnesses? *

Please provide name and 10 digit phone number of witness(es): *

Additional Information: *

Name of person completing report: *

Title/Role: *

Email: *

LLS Staff Contact Name: *

Chapter *