Creekside Church - Incident Form

Creekside Church Incident Form

Person Filing Report

First Name

Last Name

Date Filled

Person Involved:

First Name

Last Name

Age

Gender

Other Details

Regular Attender?

Staff Member?

Visitor/Group?

Waiver/Release on file?

**Repeat for as many persons involved**

Incident Details:

Type of incident:

Behavioral

Accident

Illness

Other

Incident Location

Incident Date

Incident Time

Describe the Incident

What actions were taken afterwards?

Did this incident caus einjury or harm?

Yes

No

Did this incident include anyone age 18 or younger?

Yes

No

In case of injury or harm, please complete the following:

Identify type & bodily location of injury

Was any injury a result of a violaton of a rule, order, or law by the injured?

Yes

No

If yes, describe the violation

List any objects or equipment involved in the injury

Nature of first aid administered

Persons administering first aid

Did the injured leave the facility?

Yes

No

If yes, with whom and where did they go?

Were the police notified?

Yes

No

Was a police report filed?

Yes

No

Incident involving age 18 and/or younger

Were parents notified?

Yes

No

Who contacted parents and when?

Staff person in charge at time of incident

Adult to participant ratio at time of incident

Person Filing Report

Signature

Date of signature