Alive Ministries Incident Form
Please use this form as a guideline when reporting incidences.
Name of Person Reporting
Your answer
Date
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YYYY
Date of Incident
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YYYY
Volunteer Position
Your answer
Phone #
Your answer
Email
Your answer
Incident was
Description of Incident
Who
Your answer
What
Your answer
When (day, date, time of day)
MM
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DD
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YYYY
Where
Your answer
Names of Witnesses
Your answer
Description of circumstances: (When the incident occurred, location, time, other people present, etc.)
Your answer
Were parents/ guardians notified?
Required
Were police notified?
Required
Was an ambulance called?
Required
Hospital Name, if involved
Your answer
Other action taken if any:
Your answer
If reasonable suspicion of child abuse exists, was anyone notified?
If yes, who was notified?
Your answer
If yes, when were they notified?
Your answer
The information contained in this application is correct to the best of my knowledge.
Volunteer Signature (Full Name, Last 4 digits of SS#, if over 18.)
Your answer
Date
MM
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DD
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YYYY
Submit
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