Youth - Incident Report Form

Youth - Incident Report Form

This is for youth to fill out, so that we are able to get their version of events for incidents between youth or a youth and a staff member. This is also if something happened to a youth and an instructor did not see it happen.
Youth's Name*

Last NameFirst Name
Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Who was directly involved?*
List any witnesses *
When did the incident happen?*
Where did the incident take place?*
What happened?*
What would you like to happen next?*

Talk it out with a staff mediator presentWrite a note to each other to express yourselfNeed some space and time to yourselfStay seperated from the other individual - no contactNeed to go home
Signature*

Clear
Youth stop here.
Staff Questioning

If it is a serious issue and stories are not aligning, please interview each person involved to gather information to create a story. Questioning should take place away from the group and used just to catch any inconsistencies. Bullet point list of information is fine. Who, What, Where, When, and Why.
Staff Name*

First NameLast Name
What Happened?*
Signature*

Clear
Should be Empty:

Youth stop here.