Digital Incident Form Date of Incident * MM DD YYYY Time of Incident * Hour Minute Second AM PM Location of Incident * Where on the church property did the incident occur? Was the Person Involved an Adult? * Yes No Name * Name of Person involved First Name Last Name Phone * Phone number of the person involved (###) ### #### Email Email of the person involved Additional Names/Phone Numbers of Those Involved in Incident Person in Charge/Supervisor * Name of the highest ranking person in proximity to the incident. First Name Last Name Person Completing Form * First Name Last Name Person Completing Form's Phone Number * (###) ### #### Nature of Incident * Abrasion Cut Bites Puncture Bump Splinter Bruise Scratch Other Other If you selected other, please describe. How did this incident occur? * Describe the care/outcome given: * Required paramedics? * YES NO Required hospital/physician? * YES NO Were the police called? * YES NO Person resumed activity? (If injured) YES NO If child was involved in incident, parent's name: First Name Last Name Parent's Phone Number (###) ### #### Date acknowledged * MM DD YYYY Staff/Volunteer's Name * First Name Last Name Ministry Lead's Name * First Name Last Name Your form has been submitted.
