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Filed for Record 12/29/2017 11:45:18 AM - Kittitas County, WA Auditor - 201712290016 Page 13 of 16 <br />Kittitas County Fair and Fairgrounds <br />EVENT INCIDENPACCIDENT REPORTING FORM <br />Fairgrounds representative INJURED: (Patron) (Employee) (Contractor) (Other: PC "'G� ) <br />accident reported to or at scene: Name: Ji ;iZ ii n e-. F't"tc L' AGE: LIG HT: 47' <br />WT: 150 SEX: L40 <br />PHONE: <br />ADDRESS: "PC tx) X <br />CITY:C- AV nsbu(`CI STATF_�k)A ZIP: `` u <br />— " <br />SITE NAME/LOCATION: (Indoor) (Outdoor) <br />TYPE: atr <br />INJURY: / <br />DATE: _9,1/1 -CSI -' <br />INJURED BODY PART: L.( q <br />CONDITION: Rwt ,A, -,j -i c <br />(Sprain, Fracture, Concussion, 6tc.) <br />OCCASION: <br />'❑ ARRIVING AT SITE <br />❑ SETTING UP <br />QUEUING <br />ENTERING EVENTaIDE <br />❑DU.RING EVENTTUDE: <br />(Early) (Mid) (.Late) <br />❑ EXITING EVEN URIDE <br />❑ BETWEEN EVENTS'RIDES <br />❑ <br />DEPARTING SITE <br />Name of Ride & Manufacturer <br />or Special Event: <br />AAC IVITY: <br />ER NORMAL USE <br />❑HORSEPLAY <br />❑ FIGHTING WITH: <br />❑ OTHER: <br />S.PF,CIAL CIRCUMSTANCES: <br />NONE <br />❑ UNAUTHORIZED ACTIVITY <br />❑ EQUIPMENT -RELATED <br />❑ OPERATOR -RELATED <br />❑ INTOXICAITON: <br />(Injured Person) (Other Person) <br />❑ OTHER: <br />ival) (Parade) <br />(livestock Show) (Other: ) <br />TIME <br />DISPOSITION <br />Moming <br />❑ On -Site Care Only <br />Afternoon <br />Ambulance to; <br />❑ Evening <br />t, 1K V <br />❑ After Hours ❑ .Refused Care <br />❑ Fatality <br />LOCATION: <br />❑ PARKING LOT <br />❑ WALKWAY <br />❑AT RIDE: (Mechanical) <br />(Dark) (Water) <br />❑ GAME BOOTH <br />❑ ANIMAL CAGE/STALL <br />❑ INDOOR ARENA <br />❑ OUTDOOR ARENA <br />❑ ARCADE , <br />❑ RESTAURANT <br />❑ IDWAY <br />OTHER: Gt. VS,G(C blocy) <br />SURFACE CONDITION: <br />❑ NOT APPLICABLE <br />❑ NORMAL <br />OWBT <br />❑ ICY <br />❑ LOOSE GRAVEL <br />❑ IRREGULAR . <br />❑ OTHER: <br />SITUATION: <br />❑ FALL (Slipped) (Pushed) <br />(Tripped)' (Lost Balance) <br />,] HIT BY:.� <br />❑ COLLISION WITH: <br />IF A FALL, SHOE WORNT: <br />❑ SNEAKERS <br />❑ SANDALS/THONGS <br />❑ SLIP-ONS <br />❑ LOAFERS <br />❑ WALKING SHOES <br />❑ PUMPS <br />❑ HIGH HEELS <br />[j�BOOTS <br />❑ NONE <br />❑ OTHER: <br />DESCRIBE HOW ACCIDENT HAPPENED: fjtoLjjdlo ^ Lill {„l <br />"N P'41 Ctit K <br />e+G <br />Mon . WY\i��r �i'it" �'1"tri c' ��>x; tip �) 41 `:a�ctic C� " <br />t)l'Je <br />,(,nuc vier- 1 w c,-tYuci~5 try', a <br />L;,5 i.> 4� c: h (\ t cI^ o kkx rA - vi i_. 6,t t a 10 <br />�: eC• A(Vty tawi^6c COt' �'1't�K�irk( i}tvi�iTt, tV1A :i arty_ . <br />(Over for witness inforination) <br />(print) <br />r -C +u- 1.1 ") <br />rt1�„ CYY.(' Citi <br />aLpel-A brl <br />