HRCA Incident Report 
The purpose of this form is to document any injury, behavioral issue, property damage, or other incident occurring during an HRCA chess program, tournament, or event.  Please complete this form as soon as possible after the incident.  If immediate assistance is needed, please notify the onsite club coordinator, an HRCA staff member, or HRCA Tournament Director.  

This report is not limited to incidences with students -- if you experience concerns at an HRCA tournament or other HRCA event/club, please let us know.   It is our goal to provide a fun, safe, and supportive chess environment.  HRCA has Safe Play guidelines and a Code of Conduct in place.   These are available on our website at: https://hrchessclub.org/policies/


For urgent needs, please contact: Tina @ 757-472-5909 or Jackie @ 757-447-0756
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Thank you for completing this form to the best of your ability. Your prompt and accurate report helps us maintain a safe and positive environment for all HRCA participants.
Name of person completing this form:  *
Are you completing this form for yourself or someone else?  *
If completing for someone else, please provide their name and your relationship to them:
Email Address *
Phone Number  *
HRCA program or event name: *
Where did Incident occur? *
Date of incident *
MM
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DD
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YYYY
Time of Incident *
Time
:
Who were the additional adults/ people in the room?  *
Type of Incident.  Check all that apply *
Required
Description/ additional comments
Name(s) of students or persons involved *
What was happening when the incident occurred? *
Please describe what happened in detail:  *
Did you personally witness this event? *
Required
If you did not personally witness the incident, who reported it to you?  *
Who (if anyone) was notified about the incident onsite?  *
Describe any action taken by you or others?   *
If school or host facility was notified, what actions did Administration take? 
Were there any witnesses?    Please list names and contact info (if available) so we can follow up if necessary.  *
Thank you for completing this form.   We will follow up with you shortly!
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