First Free Church Incident/Accident Report
Today's Date
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Month
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Day
Year
Date
Date of Incident
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Month
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Day
Year
Date
Incident Contact Phone Number
First Name
Last Name
Phone Number
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Area Code
Phone Number
Staff Contact
First Name
Last Name
Staff Contact Phone Number
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Area Code
Phone Number
Date(s) and Time(s) of Incident
Name(s) and Phone Number(s) of Involved Parties
If any minors are involved, include their ages and parents' names.
Location of Incident
If on campus, give the specific location.
Description of Incident
Treatment/Resolution
Was a staff member notified?
Yes
No
When was the staff member notified?
Was 911 called?
Yes
No
Did the person go to the emergency room?
Yes, transported by emergency vehicle.
Yes, went on their own/taken by family or friend.
No, but they contacted or visited their doctor.
No, he/she did not seek medical treatment.
Name of Hospital and/or Doctor
Follow-Up Comments (please add dates)
Submitted by:
First Name
Last Name
Submit
Should be Empty: