Balto KC Incident form
Details of person filling in this form
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Incident Details
Please ensure as much detail is captured as possible
Date
-
Month
-
Day
Year
Date
Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Location
Name of person(s) Injured / affected / impacted
Name of Witness / Reported by / Attended by
Type of incident
Injury to person(s)
Near miss
Child protection concern
Verbal assault
Physical assault
Bullying / Harassment
Damage to personal property
Damage to club property
Theft / fraud
In case of Injury
1st aid administered
Admitted to hospital
Treatment for shock
Treatment for hypothermia
Care required for mental wellbeing
Initially reported to
Instructor
Committee member
Child protection officer
Parent / Guardian
CI Responsible person
Club member (Junior)
Club member (Senior)
Family member
An Garda Siochana
Description of Incident (what happened, how it happened, factors leading up to the event, etc) Be as specific as possible
Please include details of locations, times and potential witnesses if applicable
Name of person(s) alleged of cause
In case of accident no cause should be directed unless you believe the person was negligent or acted deliberately
Submit
Should be Empty: