New Chapter Residence Incident Report
Date
*
/
Month
/
Day
Year
Date Picker Icon
Time
Hour Minutes
AM
PM
AM/PM Option
Resident
*
First Name
Last Name
Name of person filling out this report
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
*
First Name
Last Name
What is resident appropriate age group?
Minor Parents/Guardian Present
Minor (under 18) without Parent/Guardian
Adult (18 and over)
Older Adult
Problem Behavior
Theft
Fighting
Roughhousing or wrestling
Repeated Violation of Facility Rule
Harassment
Aggression to Staff
Aggression to Other Customers
Possession of Missing Property
Repeating Inappropriate Behavior
Bullying
Threatening harm or violence
Rude to other residents
In Off Limited Area
Tobacco Violation
Abandoned
Describe the incident with as much detail as possible
*
Observer 1
Location where incident occurred
*
Front Porch
Living Room
Hallway
Restroom room
Kitchen
Laundry Room
Stairs
Foyer
Other
Consequence
*
Verbal Warning
Written Warning
Removal Of Program
Police Called
Notes in Account?
Please Select
Yes
No
Program Participant
full name of parent/guardian spoke with
Police Action
Visited with Patron
Remove Patron
Arrested Patron
Other
Officer Name/ Badge #
Back
Next
Save
Additional information
Signature of Patron
Signature of Parent/Guardian
Signature of On Duty Signature
Back
Save
Submit
Submit
Next
Follow Up Information
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional details: video locations, parent letter etc..
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Previous Issues/Meetings
First Incident
Second Incident * Different Issue
Repeat Occurrence of Same Issue
Other
Meeting with
Adult Patron
Minor and Parent/Guardian
Parent/Guardian Only
Patron or Parent's Name Present
First Name
Last Name
Others present
First Name
Last Name
Management's Name
First Name
Last Name
Additional Staff present
First Name
Last Name
Action Taken
Patron can return with understanding of issue
One Week Suspension
One Month Suspension
One year suspension from Facility
Other
Return to Facility Date
Please Select
Option 1
Option 2
Option 3
Follow up Meeting date
Please Select
Option 1
Option 2
Option 3
Notes from Meeting
Patron Signature
Parent/Guardian signature
Parks and Recreation Management signature
Should be Empty: