Incident Statement Form
This report is for incidents that take place on Gleanings' property or involving Gleanings’ staff members on or off the Gleanings property.For your protection and the protection of others, all incidents that take place on the property of Gleanings For The Hungry must be recorded and signed by the individual who is reporting. Important: Please file a separate report for each incident.
Contact Information
Person Reporting
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Incident Details
Incident Date & Time
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Incident Location
*
List all involved individuals in the incident
*
List all witnesses of the incident
Incident Type
*
Accident / physical injury while on the Gleanings property
Theft of personal property while on the Gleanings property
Sexual misconduct / impurity (with consent) while on Gleanings property or involving a Gleanings staff member
Sexual harassment / abuse (non-consensual) while on Gleanings property or involving a Gleanings staff member
Physical violence while on Gleanings property or involving a Gleanings staff member
Damage to Gleanings property
Other
Incident Detail Comments
Incident Statement
Incident Statement: Please describe the facts of the incident. Please be thorough and include all information that may be relevant. (Please file a separate report for each incident.)
*
Truth Statement
*
I, (undersigned), agree that all statements in this report are true to the best of my knowledge. I have not added or withheld information in order to provide a false report.
Today’s Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
Submit
Submit
Should be Empty: