Incident Report - Light of Christ Church and Preschool

Name of person involved in incident: *

Parent/guardian (if minor is involved in incident):

Date of incident: *

Time of incident: *

Please indicate AM or PM

Phone number of person involved in incident: *

Address, City, State & Zip Code of person involved in incident: *

If a minor, indicate age of child involved in incident:

If a minor was involved in the incident, were the parents notified?

YES

NO

Location of the incident: *

Be specific: in what room or part of the church did the incident take place? (etc)

Clearly describe the incident: *

Include all who were involved, weather issues, property issues, etc.

Were there any visible injuries? *

YES

NO

How were the injuries treated? *

Check all that apply.

Basic First Aid

Called 911

CPR/AED

Medical attention was denied

Other

Please indicate who treated any of the injuries listed above. *

Include first and last name, if not an EMT. If no injuries occurred, enter N/A.

Are there any notes you'd like to submit about the details of treatment provided?

Was there any property damage? *

YES

NO

Were there any photographs of the incident area taken? *

YES

NO

Were there any witnesses? *

YES

NO

Please provide the name and title of the preparer of this form: *