Balto KC Incident form

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

: Hour Minutes 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
Should be Empty:

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Incident Details