CCF-11 (Official form is located at https://livegrandaz.com/documents/10184/46625/CCF11IncidentAccedentRepor.pdf

This form must be filled out promptly and submitted to the attention of “General Manager’s Office” at the Palm Center whenever any accident is identified involving a Member. Use a separate form for each injured Member.

Personal Injury

Date of Report: Date of Incident: Time of Incident:
Location where injury occurred: __________________________________________________________ City______________________________________ State______________ Zip______________
Did the injury occur on Homeowners’ Association Property? Yes No
CAM Membership #_________________
Injured Party’s Name:___________________________________________________________________
Birthdate: _________________________________Male? Female?
Home Address _________________________________________________________________________

City____________________________ State________ Zip__________ Phone (H) _________________ (W) ____________________
Was first aid administered? Yes No
if yes, by whom?

Were paramedics called? Yes No Did paramedics respond? Yes No If Minor – Parent/Guardian’s Name: Description of accident:

Description of injury:

Is injured party an employee of a subcontractor or supplier? Yes No
Name of sub/supplier _____________________________________________________________________________________________
Did an unsafe act by any person (including the injured party) contribute to or cause the incident? Yes No
If yes, identify persons involved: ____________________________________________________________________________________
Was the location inspected immediately after incident? Yes No
By Whom and When?

Incident/Accident Report

CCF-11 Page 2 of 2

Describe the lighting conditions at time of incident (e.g., natural light, dusk, dawn, artificial light)
Describe the weather conditions at the time of incident (e.g., clear, hazy, fog, rain, sleet, snow, ice)

Enclose copies of diagrams, literature, photographs, etc. of the location where incident occurred. Complete witness information.

Signature of Injured Party
Advanced medical attention refused: (complete all pertinent sections)

Witness Information - Personal Injury

Signature of Injured Party

List monitor on duty at the location at the time of the incident:
List the names of all other CAM employees who witnessed the incident:

Other Witnesses: Name #1:
Address:
Contact Information: Name #2:

Address:
Contact Information:
Name #3:
Address:
Contact Information:
Name #4:
Address:
Contact Information:
REPORT PREPARED BY: Name: Title: Address:
Contact Information: