Incident Form - NorthEast Christian Church

Date of Incident *

Location of the Incident *

Please describe the incident. *

Name(s) of the individuals involved and their role in the incident. *

There will be a section below for Staff, Medical, or Safety Team Members. If unknown, please mark N/A

Names of witnesses (if applicable) *

Which teams were involved? *

Safety Team

Medical Team

Staff

Elders

Team members involved: *

If the individual is a minor, were the parents/guardians contacted? *

Yes

No

Were Police, Fire, or EMS called? *

Yes

No

Was a police report filed? *

Yes

No

Was anyone transported to the hospital? *

Yes

No

Is there anything else that you wish to include: