Safe Conduct Incident Report Form

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Incident Report Form
First Church of Christ Congregational, UCC
2183 Main Street, Glastonbury CT 06033
(860) 633-4641

Date *

Date of Incident

Name of person injured or impacted

Phone

Age

Gender

Parent or guardian (if applicable)

Name and position of reporter

1. Briefly describe the nature and extent of the abuse/accident, including specifics such as date, time, and location.

For playground incidents, please list the equipment or apparatus where the incident occurred. Indicate if first aid was administered and if normal activity resumed.

Describe the circumstance under which you became aware of the incident.

Including information about the witnesses.

Witnesses

Names and phone numbers

3. Indicate action taken by staff and/or volunteers.

Include the names.

4. Please give any other information which you think might be helpful in establishing the cause of the incident(s) and/or the

person(s) responsible for it.

Signature of Reporter *

I have read the above form and by checking the box, sign and indicate my agreement with its terms. I agree that checking the box will be the electronic representation of my signature for all purposes on this document just the same as a pen and paper signature.

Once you have determined that a report is necessary, please submit this form within 24 hours to the Pastors, the President or the program staff.

UPDATE: Please submit this form within 12 hours of an incident.

By submitting this form, you accept the Mollom privacy policy.

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Safe Conduct Incident Report Form

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FIRST CHURCH OF CHRIST CONGREGATIONAL
Glastonbury, Connecticut

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Search form

Safe Conduct Incident Report Form

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FIRST CHURCH OF CHRIST CONGREGATIONALGlastonbury, Connecticut

FIRST CHURCH OF CHRIST CONGREGATIONAL
Glastonbury, Connecticut