Incident Report
Who is Reporting this Incident?
*
First Name
Last Name
Email of Person Reporting
*
example@example.com
Date and Time of Incident
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Name of Involved Party
*
First Name
Last Name
Phone Number of Involved Party
Please enter a valid phone number.
Format: (000) 000-0000.
Email of Involved Party
example@example.com
Is this person an employee of Connection Pointe?
*
Please Select
No
Yes
Witness(es)
*
Type of Incident
*
Injury or Medical
Theft or Criminal Activity
Property Damage
Injury or Medical Incident
Relationship to Connection Pointe
*
Employee
Member
Guest
Was EMS Called?
*
Yes
No
Was the Individual Transported to the Hospital?
*
Yes
No
Full Description of Incident
*
Theft
Item(s) stolen or missing
*
If/when possible, please include asset info
When and where was the item(s) last seen?
*
Names of any/all parties involved
*
Was Law Enforcement Contacted?
*
Yes
No
Property Damage & Injury
Full Description of Incident
*
Include any property that was damaged (church and personal)
*
Actions Taken
Upload Any Photos
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