INCIDENT REPORT Member Involved First Name Last Name Age Incident Information Date * MM DD YYYY Time * Hour Minute Second AM PM Location * Program/activity during incident * Detailed Description of Incident Description of Incident * What was this individual's role or behavior during the incident? * Were there any contributing factors specific to this individual? * Was there any property damage caused by this individual? * Yes No If yes, Describe the nature and extent of the damage: Immediate Actions Taken What immediate actions were taken concerning this individual? * Was law enforcement or other authorities contacted regarding this Individual? * Option 1 Option 2 If yes, which authorities were contacted? Follow-Up Actions What follow-up actions have been or will be taken concerning this individual to prevent recurrence? * Name of parent/guardian notified * First Name Last Name Are there any ongoing concerns related to this individual following the incident? * Yes No If yes, explain: Additional Notes or Observations: Reporter Information Name * First Name Last Name Position * Incident report submitted.