FBCH Incident Form

Injured Party First Name

Injured Party Last Name

Birthdate

Gender

Phone Number

Email

Reporting Party First Name

Reporting Party Last Name

Phone Number

Email

Incident Details

Incident Location

Classroom

Bethany Hall

CLC

Worship Center

Playground/Outside

Nursery

Other..

If other, please indicate location

Action Taken:

Parent Contacted

Conference Requested

Ice Given

Washed/Cleaned

911 Called

Other

If other, please indicate action taken:

Detailed description of incident

Additional Notes or Comments

Signature

Date Input