Incident Report Form
To be completed
Incident Details
Date of incident:
Type of incident:
Specific Location:
Day of the week:
Time:
Affected Person
Full Name:
Address:
Phone number:
Email:
Date of Birth
Report
Reported by:
Reported to:
Date reported
Reported to parent guardian (name)
Treatment Information
First Aid:
Yes
No
Doctor:
Yes
No
Ambulance
Yes
No
Details of Alleged Injury
Describe the injury
Description of Incident
Describe the incident:
Witness Information #1
Full Name:
Phone number:
Date of Birth:
Witness Information #2
Full Name:
Phone number:
Date of Birth:
Action Taken:
What action was taken:
Person Completing Form
Name:
Position:
Date:
For our review process only - please do NOT complete below this comment
Completed OR Reviewed
Form incomplete
Form completed
Reviewed by minister and wardens
Minister
Minister's Name
Date sighted by minister
Minister's Comments
Open or closed by the minister
Open
Closed
Wardens
Wardens Name
Date sighted by warden
Warden's Comments
Open or closed by Wardens
Open
Closed
Open or closed
Closed date
Submit