"Incident Report Form"

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Incident Report Form
Injury
If reporting suspected abuse, please use the back of this sheet.
Name of injured person: _____________________________________________________________________
!
 male  female
Age: _________________________________________________________________
Parent / guardian of minor child: !
_____________________________________________________________
Name of person filing report: _________________________________________________________________
!
Job description / title: !
_____________________________________________________________________
Witnesses: ________________________________________________________________________________
!
!
_______________________________________________________________________________________
!
About the Injury
Date accident occurred: _____________________________________ ! Time: _____________________ am/pm
Date accident reported: _____________________________________! Time: _____________________ am/pm
Where accident occurred: !
_____________________________________________________________________
Describe how the accident occurred: !
____________________________________________________________
!
__________________________________________________________________________________________
What part of the body was injured: !
______________________________________________________________
Describe injuries in detail: !
_____________________________________________________________________
!
__________________________________________________________________________________________
Was any first aid given? If so, please describe: !
_____________________________________________________
!
__________________________________________________________________________________________
Was medical attention sought?  yes 
no
Date: ________________________ Time: !
_________________
Name of doctor / hospital: !
_____________________________________________________________________
Administrative Board Review
Can anything be done (or should anything have been done) to prevent this type of accident? If so, please
describe on the back of this sheet.
Signature: ______________________________________________________ Date: !
______________________
Does our insurance company need to be notified?  yes  no
Rockford Reformed Church • Incident Report Form; 8/18/14 !
Form 5-A!
1 of 2
Incident Report Form
Injury
If reporting suspected abuse, please use the back of this sheet.
Name of injured person: _____________________________________________________________________
!
 male  female
Age: _________________________________________________________________
Parent / guardian of minor child: !
_____________________________________________________________
Name of person filing report: _________________________________________________________________
!
Job description / title: !
_____________________________________________________________________
Witnesses: ________________________________________________________________________________
!
!
_______________________________________________________________________________________
!
About the Injury
Date accident occurred: _____________________________________ ! Time: _____________________ am/pm
Date accident reported: _____________________________________! Time: _____________________ am/pm
Where accident occurred: !
_____________________________________________________________________
Describe how the accident occurred: !
____________________________________________________________
!
__________________________________________________________________________________________
What part of the body was injured: !
______________________________________________________________
Describe injuries in detail: !
_____________________________________________________________________
!
__________________________________________________________________________________________
Was any first aid given? If so, please describe: !
_____________________________________________________
!
__________________________________________________________________________________________
Was medical attention sought?  yes 
no
Date: ________________________ Time: !
_________________
Name of doctor / hospital: !
_____________________________________________________________________
Administrative Board Review
Can anything be done (or should anything have been done) to prevent this type of accident? If so, please
describe on the back of this sheet.
Signature: ______________________________________________________ Date: !
______________________
Does our insurance company need to be notified?  yes  no
Rockford Reformed Church • Incident Report Form; 8/18/14 !
Form 5-A!
1 of 2
Suspected Abuse / Neglect
To be reviewed by the Abuse Prevention Team within 24 hours of the incident.
Note: This does not satisfy your legal reporting obligations.
Name of person filing report: _________________________________________________________________
!
Job description / title:!
______________________________________________________________________
Name of alleged victim: ______________________________________________________________________
!
 male
 female
Age: ________________________________________________________________
Parent / guardian of minor child: !
_____________________________________________________________
Description of the circumstances
(when it occurred, location, time, people present): !
_____________________
!
__________________________________________________________________________________________
Description of the incident
(who, what, when, where, witnesses):!
_____________________________________
!
__________________________________________________________________________________________
If reasonable suspicion of child abuse exists, when was Children’s Protective Services notified? ________
!
!
__________________________________________________________________________________________
Caller’s name: _____________________________________________________________________________
!
Caller’s signature: __________________________________________________________________________
!
Other action taken, if any: ___________________________________________________________________
!
!
__________________________________________________________________________________________
Prevention / Notes
!
__________________________________________________________________________________________
!
__________________________________________________________________________________________
!
__________________________________________________________________________________________
!
__________________________________________________________________________________________
!
__________________________________________________________________________________________
!
__________________________________________________________________________________________
!
__________________________________________________________________________________________
!
__________________________________________________________________________________________
Rockford Reformed Church • Incident Report Form; 8/18/14 !
Form 5-A!
2 of 2
Page of 2