Incident Report Form

Incident Report

Complete this form when youth break program rules and/or involved in an incident or emergency.

Date of Incident

Youth's Full Name

First Last

Time of Incident(Required)

Type of Incident(Required)

Other Concern- Describe below

Name of Person(s) Involved in Incident(Required)

Physical Injury Apparent(Required)

Explain Details of the Incident(Required)

Action Taken by Youth Advocate(Required)

Youth Advocate Full Name(Required)

First Last

Youth Advocate Signature

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