Incident Report

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Incident Report

for Central WI Royal Family Kids summer & mentoring program

Report Date *

Please specify the name of the primary individual involved and indicate if adult or child.

YYYY

Name *

Please specify the name of the primary individual involved and indicate if adult or child.

Incident Date *

YYYY

Incident Time *

Time

Incident Location *

Involved Parties

Please indicate all parties involved. Including witnesses to the incident.

Incident Type *

What is the nature of the incident?

Abuse Allegation

Behavioral Issue

Health Concern

Physical Altercation

Physical Injury

Suicidal Ideation/Self Harm

Verbal Altercation

Other:

Required

Incident Narrative *

Please provide all relevant details regarding the incident.

Immediate Interventions

If not addressed in the narrative, what interventions were implemented?

Recommendations for Further Action

Notifications

Who was notified regarding this incident?

Camp or Club Director

Camp Social Worker

Parent/Legal Guardian

Caregiver

Agency Caseworker

Facility Owner

Police

Other:

Report submitted by...

Please indicate your name, position, and contact.

Submit

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