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:
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CT
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DE
FL
GA
GU
HI
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ID
IL
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OK
OR
PA
PR
PW
RI
SC
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TN
TX
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VT
WA
WI
WV
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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
Did
Did Not
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: