Inside Out Club Incident Report

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Call Executive Director Marion Ruthig (630-352-9089) if any issues or behavioral concerns arise during the lesson. Prepare this report for any accident, injury or unusual incident. Submit this form within 12 hours or the incident.

Email *

Name and role of person completing this form *

Date of the incident *

YYYY

Time of the incident *

Time

Location of the incident *

Name(s) of person(s) involved in the incident *

Description of the incident *

Date incident was reported *

YYYY

Incident reported to *

How was incident reported to IOCD *

Called the Executive Director

Emailed the Executive Director

Spoke to the Executive Director or IOCD staff in person

Other:

Any other information you'd like to provide in regards to this incident

Submit

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