Incident Report Form

Incident Report Form
Nature of Incident (select all that apply)*

AccidentInjuryInappropriate Behaviour (Ex. Bullying, Discrimination, etc.)Property / Equipment DamageHazard (Fire, Contaminant Exposure, etc)Security IncidentNear Miss (Identified potential for injury or damage)Other
Name of Individuals(s) involved*
Contact Information of Individual(s) involved.*
(*Record for adults and minors who are not registered in church programs)
Age/Grade of Individual(s) involved (If minors are involved)

NurseryPreschool / KindergartenGrade 1 - 3Grade 4 - 6Grade 7 - 9Grade 10 - 12
Time of Incident*

Hour Minutes

AM/PM Option
Date of Incident*

MonthDayYear
Date
Location of Incident*
Personnel Present at Time of Incident*
Description of Incident*
What happened?
Course of Action Taken*
If minors were involved, were Parents/Caregivers contacted?

YesNoN/A
Parent/Caregiver Response if contacted
Name of Person Filing the Incident Report*

First NameLast Name
Email Address of Person Filing the Incident Report*
A copy of the incident report will be sent to this email address.
Signature of Person Filing the Incident Report

Clear
Name of Witness (Witness must be unrelated to the Personnel who is filing the report)*

First NameLast Name
Primary Contact Information of Witness *
Email or Phone Number
Should be Empty: