MAC Incident Report Form

This form should be used to document any incident at the Mountain America Center Campus. These Incidents include slips, falls, fights, and sickness. This form should also be used to report any issues that could set the Mountain America Center up for litigation.

Name of Person Reporting*
Date of Report*
Department*
Your Role*Department Director/ManagerSupervisorSecurityUsherTicket TakerGuest Services
Incident Description*
Event Attending*
Incident Date*
Incident Approximate Time*
General Location*Mountain America CenterHero ArenaBlue Cross of Idaho Conference CenterIron Horse RV and Trailers Parking LotTeton Auto Group Plaza
Exact Location*
Incident Type InjuryEjectionAccidentIllness
Description of Incident*
Description of Hazard in Area (If Applicable)
Injury Information (If Applicable)
Select All That Apply Medical Treatment RequiredFurther Medical Aid RequiredTreatment on SiteFatalRefused TreatmentN/A
If Refused Care, Name of EMT That Received Refusal
Transported to Medical Facility
Date Left
Time Left
If Returned, What Time
Patron Information Information pertaining to the individual in question.
Individual Involved
Address
Phone Number
Date of Birth
Description of Person Involved
Witness 1 Information
Witness 1 Statement
Witness 2 Information
Witness 2 Statement
Witness 3 Information
Witness 3 Statement
Please add Photos that are important for this report.