Incident Report Form

Date of Incident(required)

Time of Incident(required)

Person filling out this report (Name)(required)

Email of Person filling out this report(required)

Type of incident (select all that apply) Behavioral

Accident/Injury

COVID-19 Exposure

Illness

Other (describe below)

"Other" description

Where the incident occurred (Select one)(required)

"Other" location

Name(required)

Address

City/State

Date of Birth

Phone

Are they a minor?(required) Yes

No

Parent's Name

The affected person is a: Camper

Staff

Visitor

Volunteer

Staff Family Member

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:

Witness #1 Name

Witness #1 Phone Number

Witness #2 Name

Witness #2 Phone Number

Witness #3 Name

Witness #3 Phone Number

Three Trails Camp & Retreat Center

Incident Report Form

Affected Person’s Information:

For Minors:

List any witnesses to the incident:

Hours & Info

Three Trails Camp and Retreat Center

Three Trails Camp & Retreat Center

Incident Report Form

Affected Person’s Information:

For Minors:

List any witnesses to the incident:

Share this:

Like this:

Hours & Info

Three Trails Camp and Retreat Center