Incident Report Form

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Thank you for your response. ✨

Date of Incident (YYYY-MM-DD)

Time of Incident (include AM or PM)

Person filling out this report (Name)

Email of Person filling out this report

Phone number of Person filling out this report

Person filling out this report is:

Type of Safe From Harm Incident

“Other Incident” description

Where the incident occurred (Select one)

“Other” location. If off camp, please include city, state.

Person(s) Affected by this incident:

Please provide the following information on Affected Person(s): First & Last Name, Gender, Age, The affected person is a: camper, staff, visitor, volunteer, or staff family member, Address, City, State, Parent/Guardian (for minors), Phone number of affected person.

Affected Person #1:

Affected Person #2+ If more than 2 affected persons, please include additional persons’ information here.

Alleged Perpetrator(s)

Please provide the following information on Alleged Perpetrator(s): First & Last Name, Gender, Age, he alleged perpetrator is a: camper, staff, visitor, volunteer, or staff family member, Address, City, State, Parent/Guardian (for minors), Phone number of alleged perpetrator(s).

Alleged Perpetrator #1:

Alleged Perpetrator #2+ If more than 2 perpetrators, please enter all additional persons’ information here.

Incident Description

The following narrative describes, to the best of my abilities, what actually occurred. Describe the sequence of activity in detail including what the affected person was doing at the time:

The following action was taken. Please note if any notifications were made to CPS, EMS, Parents/Guardians, SFH Hotline, Chesterfield, etc. :

Incident Witnesses/Other Parties:

List any witnesses to the incident or anyone else you are aware of that knows about this incident. This includes staff, campers, volunteers, etc.

Three Trails Camp & Retreat Center