1
Incident Classification
Basic incident facts — attraction, time, and severity level
Before completing this report: Ensure the guest has been attended to, EMS has been contacted if required, and your direct supervisor and safety director have been notified. This form does not replace verbal notification to management.
Guest Injury
Guest Illness / Medical
Equipment Malfunction
Guest Conflict / Altercation
Near Miss
Property Damage
Staff Injury
Other
Level 1
Minor — first aid only, guest declined transport
Level 2
Moderate — medical evaluation recommended or requested
Level 3
Serious — EMS called, hospitalization possible
Level 4
Critical — life-threatening or fatality. Ride shutdown mandatory.
2
Guest Information
Primary involved party — do not speculate, record only what is stated or confirmed
Yes — ID provided
Declined to provide
Unable to provide (condition)
Minor — guardian present
Alert & responsive
Distressed but conscious
Unresponsive
Unconscious
Yes — met all requirements
Unknown — not confirmed
No — restriction not enforced
No — guest bypassed restriction
Count of additional involved parties beyond the primary guest above.
3
Injury & Medical
Describe only what was directly observed or reported by the guest — do not diagnose
Yes — injury observed or reported
No visible injury — guest complaint only
Unknown at time of report
Medical Response
First aid administered on-site
EMS / 911 called
Guest transported by ambulance
Guest self-transported to medical facility
Guest declined all medical treatment
Guest signed medical refusal form
4
Incident Sequence
What happened — in chronological order, direct observation only. No speculation about cause.
Queue / Waiting area
Loading / Boarding
In-ride / During operation
Unloading / Exit
Post-ride / Exit ramp
Not during ride operation
Yes — confirmed by operator
Yes — visually confirmed
No — not confirmed prior to dispatch
Unknown
N/A — incident not restraint-related
Yes — normal operation
No — anomaly observed
Unknown
This narrative is a legal record. Write as if you will be asked to read it in a deposition.
Yes — immediately shut down
Yes — shut down after guest cleared
No — returned to operation
N/A
5
Emergency Response & Notifications
Who was notified, when, and what actions were taken by management
Management Notifications
Safety Director notified
General Manager / Park Director notified
Maintenance / Engineering notified
Risk Management / Insurance contact notified
Legal counsel notified
Required for Level 3 and Level 4 incidents
Regulatory Notifications
State regulatory authority notified
Required threshold varies by state — check your NJ DCA / state ride safety office obligation
CPSC report filed or flagged
OSHA notification required
Required if employee involved and meets recordable threshold
Yes — area secured
Partially — some preservation
No — returned to operation
Photos taken at scene
Surveillance video secured / flagged for retention
Pre-opening inspection log secured
Operator log secured
Maintenance records secured
6
Witnesses & Staff Present
Record all parties who observed the incident or were present on the platform
No witnesses added yet.
// ADD WITNESS / STAFF
Yes — camera coverage confirmed
Partial — limited coverage
No — no coverage at this location
Unknown
7
Review & Submit
Confirm all information before final submission — this record cannot be edited after submission
Certification: By submitting this report I certify that the information recorded is accurate to the best of my direct knowledge and observation, and that I have not included speculation, opinion, or unverified third-party claims without identifying them as such. I understand this document may be used in regulatory review, legal proceedings, and insurance claims.
I certify the above statement is true and accurate