Incident Report

Last Updated: August 3, 2016 Contact: Katie Chow

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Veritas Kids – Incident Report

Team Lead (This form must be completed by the attending Team Lead) _______________________

Child’s Name _____________________________________________Birthdate ___ / ___ / ___

Father’s Name ______________________________________ Phone # (___) ______________

Mother’s Name _____________________________________ Phone # (___) ______________

Date of Incident ___ / ___ / ___

Describe the nature of the incident.

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Was first aid administered? (Yes / No) If so, describe the care given.

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

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Was 911 called? (Yes / No) If so, what is the name of the attending physician? _________________

Names of Veritas Kids Volunteers who were present in the room: ___________________________

Were the parents informed the day of the incident? (Yes / No)

Was a follow up phone call made? (Yes / No) Date of the call ___ / ___ / ___

Remarks:

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Signature of Team Lead on duty & Signature of Kids Ministry Director

Team Lead _______________________ Kids Ministry Director _________________________