Slick City Pigeon Forge - Incident Reporting Form

Slick City Incident Reporting Form

Pigeon Forge, TN
Agency Claims Contact
CATEGORY OF INCIDENT
PARK NAME
PARK LOCATION
PARK GL POLICY NUMBER
GUEST INCIDENT TYPE / INJURY?
INCIDENT CLASSES IMPORTANT! SERIOUS INCIDENTS ARE SENT TO THE INSURANCE CLAIMS GROUP ONLY
INCIDENT DEFINITIONS

Class X (Exterior Park GL Incident)

Class H (Health Compliant Only I.E. COVID-19 Illness or Food Illness)

Class 0 Incident Without Injury

Class 1 Minor/Return to Participation

Class 2 Minor/Did not Return to Participation

Class 3 Moderate/Will Not Seek Medical Follow Up

*Class L/E Serious - Legal Documents Received

*Class 4 Serious - Left with Medical Professional or Will Seek Professional Medical Attention. Medical Expenses Incurred. (If No Professional Medical Attention and Medical Expense Incurred, Class 3 is Appropriate Incident Class Level Choice)

*Class 5 Serious - Paralysis or Death

*Incidents Reported to Claims Group
IMPORTANT: WAS EMS (EMERGENCY MEDICAL SERVICES) CALLED TO THE PARK & PATRON TRANSPORTED OR, DID THE PATRON GO DIRECTLY TO PROFESSIONAL MEDICAL CARE?
INCIDENT / INJURY CLASSES
INCIDENT / INJURY PRELIMINARY ROOT CAUSATION
Name of Guest

First Name Last Name
Date of Birth of Guest

MonthDayYear
Date
Is Injured Guest a Minor?
DATE OF INCIDENT / INJURY

MonthDayYear
DateHourMinutesAM/PM Option
DATE OF INCIDENT / INJURY SUBMISSION

MonthDayYear
DateHourMinutesAM/PM Option
INCIDENT LAG TIME REPORTING
AUTOMATIC CALCULATION
Guest Male or Female?
Phone Number of Guest

Area CodePhone Number
If Guardian or Accompanying Adult, Enter Name:

First Name Last Name
If Guardian or Accompanying Adult, Enter Phone Number:

Area CodePhone Number
Was Another Guest / Employee Injured?
If Yes, (Another Guest Involved), Complete Full Name & Age
INCIDENT KPI's
TIME OF DAY INCIDENT / INJURY
DAY OF WEEK INCIDENT / INJURY
INCIDENT / INJURY BUSINESS HOURS EVENT
PARK PROGRAM INVOLVED? SPECIAL PROGRAM?

Other
Was Blood or Bodily Fluids Involved with Incident / Injury?
Was BBP Cleaning Kit Available if Blood or Bodily Fluids were involved?
Were Police Called?
Was a Weapon Involved?
If Weapon, What Kind?
Type of Incident?
Type of Injury
Body Part
Incident - Injury Attraction or General Area
Incident - Injury Location
Attraction / Area Name
Question Triggers for Special Distribution
Guest Patron Rules Sign Visible at Attraction of Incident - Injury?
Guest Patron / General Park Rules Signs Visible at Entrance/Waiver Station?
Guest Requested Contact for Claims?
Guest Requested Financial Assistance With Medical Bill?
Injury-Incident is Mentioned on Social Media, Social Media Threat or Reporter Inquiry?
Waiver for Guest?
Park Waiver Kiosks Operational?
Online, Park Kiosk, or Paper Waiver?
Video Footage Available of Incident/Injury?
Incident Video Access Link(s)
INCIDENT VIDEO UPLOAD

2 minutes before & 2 minutes after Incident. Max 300 MB Video. All other Videos of Patron at the park to be saved locally in case TPA or Defense Counsel needs them. (Entrance, POS station, Using other attractions, etc.). For L/E, 4 & 5 Class Level Incidents.
Incident Video Upload

Browse Files

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Incident Short Description

Description of incident - injury. (140 Character Limit) 0/140
GUEST INCIDENT PHYSICAL DESCRIPTION (Clothing, Clothing Color, etc.)
INCIDENT INFORMATION ATTACHMENTS

FOR LEVEL L/E, 4 or 5 Incidents - OPTION FOR OTHER INCIDENT LEVELS
Legal Documents Received (LOR, Subpoena, Legal Complaints, Lawsuits, etc.) Attachment(s)

Browse Files

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Waiver Attachment

Browse Files

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Witness/Staff Statement Attachments

Browse Files

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Training Documents

Browse Files

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Picture of Incident Area Attachments

Browse Files

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MFG Attraction Operations Manual Attachment

Browse Files

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MFG & Attraction Inspection Files

Browse Files

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If Form Update, Name of Person Updating Incident Information
PARK GM or PARK CONTACT
To Receive Copy of Report Submission
PARK OPERATIONAL?
PARK ATTRACTION INVOLVED OPERATIONAL?
Is the State Involved in any Park Injury Safety Inspection?
Signature
Report Completed by Full Name:
Report Completed by Title
CONFIDENTIAL INFORMATION ATTORNEY/ CLIENT PRIVILEGE

LEGAL CONFIDENTIALITY NOTE: This electronic message transmission contains information from the law firm, which may be confidential or privileged. The information is intended to be for the use of the individual or entity named therein. If you are not the intended recipient, please immediately delete this e-mail and be aware that any unauthorized disclosure, copying, distribution, or use of the contents of this information is strictly prohibited.
Should be Empty:

Slick City Incident Reporting Form

INCIDENT CLASSES IMPORTANT! SERIOUS INCIDENTS ARE SENT TO THE INSURANCE CLAIMS GROUP ONLY

INCIDENT KPI's

Question Triggers for Special Distribution

INCIDENT VIDEO UPLOAD

INCIDENT INFORMATION ATTACHMENTS

CONFIDENTIAL INFORMATION ATTORNEY/ CLIENT PRIVILEGE