Mob City Junior Roller Derby Incident Report

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For all injuries or sexual abuse/molestation cases, please fill out an incident report. Please include your contact information for follow up.

IMPORTANT:
For all cases related to sexual abuse/molestation, we are required by law to report this to Child Protective Service and contact police. We are committed to cooperating in every way to ensure the safety of children in our program.

For all injuries, once this form has been filled out, we will email you a copy of our insurance form to fill out and submit for all medical claims.

Name of Reporter

Reporter Phone Number

Reporter Email

Incident Type *

Injury

Sexual Abuse/Molestation

Other:

Required

For Injury, has an insurance claim been filed?

Yes

Clear selection

For sexual abuse/Molestation incident, has a CPS report been filed?

Yes

Clear selection

For sexual abuse/Molestation incident, has a police report been filed?

Yes

Clear selection

If a police report has been filed, please enter the contact information for the reporting officer, precinct, and phone.

Incident Date

YYYY

Incident Time

Time

Injured Person Name *

Location of incident (include address) *

Incident Description *

Name/Role/Contact of Parties Involved

Name/Role/Contact of Witnesses

What follow up action do you want to have happen?

Submit

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