Kentucky Department of Agriculture
Division of Regulation and Inspection
Amusement Rides and Attractions Inspection Section
107 Corporate Drive
Frankfort, Kentucky 40601

OFFICE:  502/573-0282     FAX:  502/573-0303
EMAIL:
chad.halsey@ky.gov

AMUSEMENT RIDE INCIDENT REPORT FORM 
Date of Incident:   Time of Incident:
Date Report Sent: Time Report Sent:
COMPANY INFORMATION:
Company Name:   Business ID Number:  
City: State:   Zip:
Owner:   Phone:
RIDE OPERATOR(S):
Name:
Address:
Name:
Address:
INCIDENT INFORMATION:
Ride/Attraction Name:
Manufactuer:   Serial Number:
Location of Accident:
NAME AND ADDRESS OF FIRST PERSON INJURED:
Name: Sex: Age:
Address:  Phone:
Nature and extent of injury:
Name/Location of treating facility or person:
Description of Incident:
NAME AND ADDRESS OF SECOND PERSON INJURED:
Name: Sex: Age:
Address:  Phone:
Nature and extent of injury:
Name/Location of treating facility or person:
Description of Incident:
NAME AND ADDRESS OF THIRD PERSON INJURED:
Name: Sex: Age:
Address:  Phone:
Nature and extent of injury:
Name/Location of treating facility or person:
Description of Incident:

I attest that the above information is accurate to the best of my knowledge.  I have assistance completing this report.  If you had assistance, please provide  the contact information  of the person assisting you below.
Name: Phone: Email:
Must be submitted within 12 hours of incident. Immediate phone call to KDA (or branch manager if after office hours) is also required.

 
Signature Owner/Lessee(typing your name is your digital signature):

Relation to Injured Person:  
Address & Telephone Number:  
Email Address: