CHILD INCIDENT REPORT
First Baptist Church Amarillo
Complete this form immediately following any incident involving a minor
SECTION 1: INCIDENT INFORMATION
Date of Incident:
-
Month
-
Day
Year
Date
Time of Incident:
Hour Minutes
AM
PM
AM/PM Option
Location of Incident:
Ministry/Program
Please Select
Preschool Ministry
First Steps
Kids Ministry
Student Ministry
SECTION 2: CHILD INFORMATION
Child's Full Name:
Age/Grade:
Parent / Guardian:
Phone:
Format: (000) 000-0000.
SECTION 3: TYPE OF INCIDENT
Type of Incident
Fall / Trip
Cut / Laceration
Burn
Allergic Reaction
Behavioral / Altercation
Illness
Bite
If Other, please describe:
SECTION 4: DESCRIPTION OF INCIDENT
Describe what happened (include how, where, and any contributing factors):
SECTION 5: RESPONSE & FIRST AID
Action(s) taken:
Response & First Aid Actions
First Aid Applied
Parent / Guardian Notified
911 / EMS Called
No Action Needed
SECTION 6: WITNESSES
Witness 1:
Phone Number:
Format: (000) 000-0000.
Witness 2:
Phone Number:
Format: (000) 000-0000.
SECTION 7: SIGNATURES
Reporting Staff / Volunteer:
Date:
-
Month
-
Day
Year
Date
Ministry Leader / Supervisor:
Date:
-
Month
-
Day
Year
Date
Submit
Should be Empty: