Safety Incident Report (Under 18)

Filling this form out on behalf of someone else? Please first provide your contact information.

Your name *

Email address *

Your Phone *

Your Role *

Campus Location *

Young Person Involved

First and Last Name *

Age *

Gender *

Date Occurred *

Time Occurred *

Location of incident/injury/illness? *

Physical place where the incident occurred

Location of incident/injury/illness? *

Physical place where the incident occurred

Safety Incident Type *

How did the incident occur? *

Give details of the events leading up to incident

What were you doing at the time of the incident? *

Please explain in detail

Please describe the actions you took? *

Include in this description if you used any medical supplies.

Please describe the circumstances if the young person appeared to be missing/unaccounted for?

Please include duration, who found the child, etc.

Were there any witnesses? *

Were emergency services required? *

Were the parents notified of the incident? *

Yes

Was the Children's Pastor/Director notified?

Yes