Incident and Issue Report

Incident and Issue Report
Use this Incident and Issue Report Form to document any incident or situation that may escalate into an issue, emergency, or crisis. If you are in doubt, fill out a report.

Examples of situations that should be reported: disruptive behavior that cannot be corrected and all redirecting measures have been attempted, an accident, injury, serious argument or disagreement, physical fight, suspected child abuse, theft, disturbing situation, or any other out of the ordinary occurrences involving Girl Scouts. This list is not all-inclusive.
- The group leader or adult in charge must complete this report as soon as possible.
- Other people involved should also complete a copy of this report as soon as possible.
- Return this report to Girl Scouts of the Green and White Mountains staff immediately.
Always inform and seek guidance from your Volunteer Support Coordinator and/or service team members. Provide them with a copy of the incident report and send a copy to the Bedford Service Center. You may be contacted for further information.

Girl Scouts of the Green and White Mountains 1 Commerce Drive Bedford, NH 03110-6835 603-627-4158 888-474-9686 girlscoutsgwm.org
Girl Scouts of the Green and White Mountains INCIDENT and ISSUE REPORT FORM

CONFIDENTIAL
Group # / Camp
Date of incident

MonthDayYear
Date
Time of incident
Place of incident
Name of person(s) involved and contact phone #(s)
Follow up of previous report

YesNo
Date initial report was filed

MonthDayYear
Date
Be complete and specific. Use quotes when possible. Feel free to use additional sheets to completely record the event. Attach copies of any letters, police reports, pictures, or related documents.
What occurred before, during, and after the incident? Please describe in sequence. Use impartial, descriptive, and detailed language.
How was the situation dealt with?
What follow-up is needed?
Please upload any photos or documents related to the incident.

Cancelof
Person preparing report
Position
Signature

Clear
Telephone
Date report prepared

MonthDayYear
Date
Time and place report prepared
Should be Empty:

Incident and Issue Report

Girl Scouts of the Green and White Mountains INCIDENT and ISSUE REPORT FORM