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 Name
First Name
Date
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/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 present
Write a note to each other to express yourself
Need some space and time to yourself
Stay seperated from the other individual - no contact
Need 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 Name
Last Name
What Happened?
*
Signature
*
Clear
Submit
Should be Empty: