Minor Incident Form for Kids Ministry

First Name of Injured Person: *

Last Name *

Date of Incident: *

Time of Incident *

Campus *

Is this for:

Name of Parents (if child was injured) *

Description of Incident: *

Type of incident (check all that apply) *

Where incident/injury Happened *

Describe specifically what room unique to your campus where the injury occurred. *

Incident happened during *

Describe in more detail the activity that was happening during the injury. *

Action taken (check all that apply) *

Was any blood present during the injury *

Yes

No

Following Community CPR and Blood Borne Pathogen training, how was the blood handled? *

Name of Volunteer or Staff Supervising area: *

Name of Witness *

Signature of person completing this form: *

Print Name *

Person completing this form

Email *

Signature of Witness *

Print Name *

Witness

Email

If you would like a copy of this report

Were the parents notified? *

Yes

No

What was the discussion like? *

Signature of Parent/Guardian

Print Name

Email

If you would like a copy of this report

Todays Date & Time