Children's Ministry Incident Report

This form must be completed by the attending Lead Teacher.

Lead Teacher

Date of Incident

Child's Name

Child's Birth Date

Father's Name

Telephone #

Mother's Name

Telephone #

Name of Guardian if the child was brought by someone other than the parent

Telephone #

Describe the nature of the incident

Was first aid administered? if so, describe the care given

Yes No

Were any other children involved in the accident? if yes, what are their full names

Yes No

Was 911 called?

Yes No

If so, the attending physician

Name of witness use Remarks below if more than two

Telephone #

Name of witness

Telephone #

Were the parents informed the day of the incident?

Yes No

Was a follow up phone call made?

Yes No

Date of the call

Who made the call?

Who received the call?

Remarks

Signature of Lead Teacher on duty

Date

Signature of Children's Ministry Director

Date

(541) 673-5234
www.clfroseburg.com

Give the completed report to the Children's Ministry Director the same day. Clearing the form erases the draft from this browser; it is the only copy, so print or save the PDF first.