The Village Indiana Incident / Mandated Reporting Form
Submit the required incident details as mandated.
IMPORTANT: This form documents The Village Indiana's internal program response to an incident. It does NOT replace the legally required report to state or local child protective services / law enforcement under the Mandatory Reporting of Child Abuse and Neglect Policy. If you suspect abuse or neglect, report it to the appropriate authorities immediately, in addition to completing this form.
Incident Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Incident Time
Hour Minutes
AM
PM
AM/PM Option
Hub
Please Select
United In Christ Church
Exit Church
Living Water
InerG Impact
HUTS Group ID
Please Select
UIC-B1
EXIT-B1
LW-B1
INERG-G1
INERG-B1
Reported By
Youth(s) Involved
List all youth involved in this incident.
Incident Type
Please Select
Injury
Behavioral
Suspected Abuse/Neglect
Transportation
Policy Violation
Other
Description
Describe what happened, including date, time, location, and who was present.
Immediate Action Taken
Describe any action taken at the time of the incident.
Mandated Report Filed?
Yes
No
Agency Name
Report Number
Report Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent Notified?
Yes
No
Parent Notified Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Lead Champion/ED Notified?
Yes
No
Lead Champion/ED Notified Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Status
Please Select
Open
Monitoring
Resolved
Resolution Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: