Incident Report Form

Incident Report

Please complete this report for any accidents, unexpected incidents involving minors, any call of fire/medical/police/mental health services, or any other incident in which you or another person felt or reported feeling unsafe. Thank you for your assistance.

Reporter Info
Date of Incident*
Date Report Filed*
Name of Person Filing Report*
Contact Info for Person Filing Report*

Please list a good way to contact you if needed--phone or email is okay.
Description of Incident
Where did the incident occur?*
Please describe the incident.*
If any injuries, please describe the nature of the injuries. List names of those injured if known.
Describe any actions taken in response to the incident.*
List any other people involved in or witness to the incident.
If a minor (under 18 years) was involved, was a parent/guardian notified?*
- Yes
- No
- Multiple attempts were made to reach a parent/guardian but were not successful.
- No minors were involved.
I notified the following people at Shoreline Covenant of the incident:
- Select All
- Pastor Ben
- Pastor Sally
- Board Chair
- Other
What other person did you notify?
Email
This field is for validation purposes and should be left unchanged.

Incident Report

Reporter Info

Description of Incident