Incidents That Should Be Recorded
- Physical and verbal altercations
- Injuries and medical emergencies
- Damaged or stolen property
- Unlawful activity (drugs, weapons, etc.)
- Problems with children or nursery staff
Sample
Church Name: [CHURCH NAME] Location: [LOCATION]
Describe the Incident: [DESCRIBE THE INCIDENT]
- Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [EMAIL] Address: [ADDRESS]
- Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [EMAIL] Address: [ADDRESS]
If yes, enter the witnesses’ names and contact info:
- Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [EMAIL]
- Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [EMAIL]
Were children or youths involved in the incident? ☐ Yes ☐ No
If yes, enter their name(s): [NAME(S) OF CHILDREN/YOUTHS]
Was the parent/guardian notified? ☐ Yes ☐ No
If yes, enter their name(s): [NAME(S) OF PARENTS/GUARDIANS]
Name of person who contacted parent/guardian: [NAME OF PERSON]
Staff person in charge at time of incident: [NAME OF STAFF PERSON]
If yes, was a report filed? ☐ Yes ☐ No
Was medical treatment provided? ☐ Yes ☐ No ☐ Refused
If yes, where was medical treatment provided? ☐ On site ☐ Hospital ☐ Other: [OTHER]
Full Name: [FULL NAME] Title/Role: [TITLE/ROLE]
Signature: Date: [MM/DD/YYYY]