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Lowell Makes Safety Incident & Injury Report
Please fill out this form factually, to the best of your ability and memory, if you observed an injury or incident occur at Lowell Makes. Your information will help us correctly address the situation and develop better policies and procedures to make our community even safer.
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Email
*
Your email
Background
All Lowell Makes Members sign a Membership Agreement, in which they promise, among other things, to maintain a safe environment for themselves and others. They commit to Individual Safety, Shared Safety, and Tolerance of Feedback.
Name
*
Name of the person involved in the incident/injury.
Your answer
Parent/Guardian
If the incident/injury involves a minor, please include the name of the parent/guardian.
Your answer
Membership Status
Lowell Makes Member
Class/Workshop Attendee
Guest of Lowell Makes Member
Visitor of Public Event
Other:
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Name of Host Member
If applicable, give the name of the Lowell Makes Member who was hosting the person named above.
Your answer
Phone Number
*
The number of the person named above, so that we may follow up.
Your answer
Date of Incident
*
MM
/
DD
/
YYYY
Time of Incident
*
Time
:
AM
PM
Location of Incident
*
Did the incident occur in an access-controlled space?
Wood Shop
Machine Shop
Elsewhere Downstairs
Upstairs
Events leading up to Incident
*
What was the person named above doing prior to the Incident?
Your answer
Events involved in the Incident
*
What happened to the person named above during the Incident? Please mention any equipment or tools involved in the Incident.
Your answer
Events immediately following the Incident
*
What happened in reaction to the Incident?
Your answer
Description of Specific Injuries
*
Parts of body and nature of any injuries occurring as a result of the Incident.
Your answer
Treatment of Injuries
*
Specific treatments administered to above injuries.
Your answer
Additional Information
Any other information relevant to the Incident.
Your answer
Name of Filer
*
Name of the person filling out this Incident Report.
Your answer
Phone Number of Filer
*
The number of the person filling out this Incident Report, so that we may follow up.
Your answer
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