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									                               SOUTH FLORIDA CHURCH OF CHRIST

                                            Youth Ministry
                                            Incident Report

     To be completed by Youth Ministry Coordinator or Teen Coordinator regarding accidents or injuries to
     children or teens involved in ministry activit ies. PLEA SE PRINT LEGIBLY, IN BLUE OR BLA CK INK .


REPORTING PARTY INFORMATION:

        First & Last Name: ______________________________________________________________
        Telephone Number: ______________________________________________________________
        Region & Sector: ______________________________________________________________
        Position (circle one):       Youth Min istry Coordinator     Teen Ministry Coordinator
        Date report co mpleted, in it’s entirety: __________________


INJ URED PARTY INFORMATION:

        First & Last Name: ______________________________________________________________
        Telephone Number: ______________________________________________________________
        Address:              ______________________________________________________________
        Sex: ____________ ,      Date of Birth: ________________ , Age if DOB unknown : _________
        Member of church (circle one): Yes / No. If yes, which Sector: _________________________
        Parents / Guard ians Names: ________________________________________________________
        Telephone/Address, if different fro m above: ___________________________________________
                             _______________________________________________________________



WITNESS ES / OTHERS INVOLVED IN INCIDENT:

Names:                                           Telephone numbers:
______________________________________           __________________________
______________________________________           __________________________
______________________________________           __________________________
______________________________________           __________________________


INCIDENT INFORMATION:

Date and Time of Incident: _______________________________________________________________
Place of Incident: _______________________________________________________________________
Describe what injured party was doing when incident occurred, any unsafe conduct or c onditions:
______________________________________________________________________________________
______________________________________________________________________________________
Describe specific in juries resulting fro m incident; note any lost time fro m work or school:
______________________________________________________________________________________
______________________________________________________________________________________
Describe medical care/emergency care provided; name of person (s), doctor(s) providing care:
______________________________________________________________________________________
______________________________________________________________________________________



ACTION TAKEN:
      Unsafe conditions to be resolved.                           Instruct volunteer workers.

        Unsafe behavior to be corrected.                          No action is required, simp ly noted.

								
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