Road Scholar Incident Report

Instructions

Road Scholar requires an Incident Report to be completed for participant injury, illness or accident requiring professional medical attention and/or hospitalization; serious mobility or cognitive issues; late arrival or early departure; death; theft; group incidents; or any significant incident or event that impacts a program. An Incident Report must be completed by the Group Leader or Program Provider staff who witnessed the incident, or has the most direct knowledge of the situation. Completed Incident Reports should be submitted to Road Scholar as soon as possible.

LiveTravel Assist, Road Scholar’s emergency assistance provider, must also be contacted if a participant:

Has a serious medical issue, or potentially serious medical issue; and
professional medical attention is needed, or if the participant is, or is likely to be, hospitalized

There are two ways program staff can notify LiveTravel Assist about a participant medical issue. They can either:

Call LiveTravel Assist to open a medical case for a participant, or
Use this online Incident Report portal to automatically notify LiveTravel Assist that they need to open a medical case for the participant.

Upon receipt of an Incident Report delivered automatically via this online portal, LiveTravel will reply to the sender to confirm that they have received the incident report and opened a medical case for the participant.

Please provide all of the information requested below. If you have any questions or concerns about a particular situation, or in the event of a serious participant or program emergency, please contact your Emergency Duty Officer (EDO) or the Road Scholar Emergency Number (617) 413-1114.

* Indicates field is required.

Participant Information

Participant First Name

Participant Last Name

Date of birth

Gender

Participant Mobile Phone

Please add country code if outside United States/Canada.

Participant Home/Alternate Phone

Is the participant traveling alone?

Incident Information

Type of Incident

Date of Incident

Location of Incident

Detailed Description of Incident

Treatment/care offered or given to participant:

Location of Participant

Participant's Current Location

Name of Hospital, Clinic or Accommodation (if applicable)

Phone Number(s) of Hospital, Clinic or Accommodation

Fax and/or Alternate Phone Number

Did the participant:

Number of days (if any) the Participant missed

LiveTravel Assist

Does the participant have a serious medical issue, or potentially serious medical issue, and has received professional medical attention or been hospitalized?

Has LiveTravel Assist been contacted and instructed to open a medical case for the participant?

Enter the LiveTravel Assist Case Number you were provided:

Should LiveTravel Assist use this Incident Report to open a case for the participant?

Confirmed:

Declined:

Additional Information

Please provide any additional information that would be helpful in understanding this incident or situation:

Program Staff Information

Group Leader/On-site Staff Name

Mobile/Primary Phone Number

Secondary Phone Number

Program Number

Program Start Date

Program Provider Name

Your Email for Copy of Incident Report

Provider/Alternate Email for Copy of Incident Report

Contact Information