City Church Incident Report

This form is to be completed by an adult witness whenever an incident requiring medical attention, discipline/conflict in a classroom or other reportable event occurs. In all cases, the parents should be informed as soon as possible and this form should be submitted to church leadership.

Your name *

Email address *

Name of Adult Supervisors *

List leaders and teachers who were in charge of the activity at the time of the incident

List the names of those who were directly involved in the incident? *

Did anyone else witness the incident?

List any adult not named above

Activity where the incident occurred *

Type of Incident *

(Select all that apply)

Minor Injury

Injury requiring medical attention by a professional

Conflict between two children

Discipline issue between an adult and child

Other

Describe the Incident *

Please include as much detail as possible. (who, what, when, where, how, why)

What actions were taken? *

Child taken to parents, Medical attention, 9-1-1 call, etc.

Recommended path forward *

What else can be done to restore relationships; Prevent this from happening again; Future training

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