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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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) *
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DD
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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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