Incident Report Form

Date of Incident

MM

DD

YYYY

Time of Incident

Hour

Minute

Second

Location of Incident

Name of Child Involved (One Report per Child)

If you did not witness the incident, who reported it?

Other Witnesses

Actions Taken (Check all that apply)

Provided First Aid

Called 911

Taken to Hospital

Notified Parent/Guardian

Notified Church Staff

Notified Authorities

Type of Incident and Description

Name of Person Completing This Report