Incident Report
Report Date
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Month
/
Day
Year
Date
Report Time
Reporters Name
Reporters Phone Number
Please enter a valid phone number.
Reporters Email
example@example.com
Incident Date
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Month
/
Day
Year
Date
Incident Time
Location of Incident
Type of Incident
Injury/Illness
Property Damage
Misconduct
Theft
Other (please specify)
Name(s) of Individual(s) Involved & Contact Information
Role/Relation to Organization:
Staff
Volunteer
Member/Participant
Visitor
Other
Names of Witnesses
Contact Number of Witness(es):
Witness(es)Email
example@example.com
Detailed Description of Incident: (Please provide a thorough account of the incident, including actions leading up to the incident, the incident itself, and any immediate actions taken:
Description of Injuries (if any): (Please detail the nature and extent of any injuries sustained in the incident:
Please describe any immediate actions taken in response to the incident such as first aid, contacting emergency services, etc
Was medical treatment provided?
Yes
No
If Yes specify the type of treatment and by whom
Follow Up Actions Required: (Please describe any further actions required, such as follow up with involved individuals, repairs, additional reporting, etc
Was the incident reported to any authorities?
Yes
No
If Yes, specify the authority and the date reported:
Additional Notes or Comments
Reviewed By
Date of Review
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Month
/
Day
Year
Date
Action Taken By Forever Kings:
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