Risen Church Incident Report

RIsen Church Incident Report
Reporting Staff/Volunteer Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
SECTION 1 - INCIDENT INFORMATION
Date of Incident

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Approximate Time of Incident
Location (Specific Room or Area) Where Incident Occurred
Full Name of Person Involved

First NameLast Name
Role/Relationship to Risen Church
Age (if under 18)
Type of Incident
If other, please explain:
SECTION 2 - DESCRIPTION OF INCIDENT
Describe the incident in chronological order and include relevant facts. Document only what you personally observed or know to have occurred. Do not speculate or assign blame.
What was happening immediately before the incident?
Were there any visible injuries?
If yes, describe the injury and location on the person's body:
SECTION 3 - ACTIONS TAKEN
What actions were taken immediately following the incident?
Was first aid provided?
If yes, describe the first aid provided and identify who administered it:
Was additional medical attention require or recommended?
If yes, please explain:
Was 911/Emergency Medical Service contacted?
Was Risen Church Leadership notified?
If yes, who was notified?
SECTION 4 - PARENT/GUARDIAN NOTIFICATION
Was the child's parent/guardian notified of the incident?
Parent/Guardian Notified:
Person Who Made Notification:
Method of Notification:
Approximate Time Parent/Guardian Was Notified:
Briefly document the information communicated to the parent/guardian:
If the parent/guardian was not notified, explain why:
SECTION 5 - REPORTING STAFF/VOLUNTEER STATEMENT
Reporting Staff/Volunteer Role During the Incident
Describe specifically what YOU personally saw, heard, and/or did: (If you did not see a portion of the incident, clearly state that in your statement.)
Reporting Staff/Volunteer Signature
SECTION 6 - ADDITIONAL STAFF/VOLUNTEER STATEMENTS
Were other staff members or volunteers present in the room or immediate area when the incident occurred?
Please list the name of each person who was present in the room or immediate area to your knowledge.
SECTION 7 - REPORT ACKNOWLEDGMENT
By signing this Incident Report, I certify that the information I have personally provided is accurate and complete to the best of my knowledge. I understand that I should report only what I personally observed, heard, or did and should not include assumptions or speculation.

I understand that this report is an official Risen Church ministry record and must be treated as confidential.
Reporting Staff/Volunteer Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

RIsen Church Incident Report

SECTION 1 - INCIDENT INFORMATION

SECTION 2 - DESCRIPTION OF INCIDENT

SECTION 3 - ACTIONS TAKEN

SECTION 4 - PARENT/GUARDIAN NOTIFICATION

SECTION 5 - REPORTING STAFF/VOLUNTEER STATEMENT

SECTION 6 - ADDITIONAL STAFF/VOLUNTEER STATEMENTS

SECTION 7 - REPORT ACKNOWLEDGMENT