Incident Report - Building Bridges

Type of Incident *

Individual's Initials *

Date of Incident *

Time of Incident *

Employee Name(s)

	Name
1
1

Location of Incident

What happened?

Were there any injuries?

If yes, please describe in detail, including any first aid/treatment

Was anyone else involved?

Manager informed?

Manager's Name

Parents notified?

Parent's Name

Ministry notified? *

Ministry notified by:

Ministry worker's name

Ministry worker's number

Did you require:

Did you contact a physician?

Doctor's Name

What was the outcome?

Is further action recommended?

Signature

Date