Balto KC Incident form

Balto KC Incident form

Details of person filling in this form
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Incident Details

Please ensure as much detail is captured as possible
Date

MonthDayYear
Date
Time

:HourMinutesAM/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 missChild protection concernVerbal assaultPhysical assaultBullying / HarassmentDamage to personal propertyDamage to club propertyTheft / fraud
In case of Injury

1st aid administeredAdmitted to hospitalTreatment for shockTreatment for hypothermiaCare required for mental wellbeing
Initially reported to

InstructorCommittee memberChild protection officerParent / GuardianCI Responsible personClub member (Junior)Club member (Senior)Family memberAn 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
Should be Empty:

Incident Details