WORD OF LIFE SANTA BARBARA

INCIDENT REPORT FORM (NOV 2024)

SECTION 1: REPORTING PERSON INFORMATION

SECTION 2: INFORMATION OF INVOLVED INDIVIDUAL (S)

SECTION 3: INFORMATION ON INCIDENT 

SECTION 4: DETAILED DESCRIPTION OF INCIDENT 

Describe in detail what happened. Do not forget the Who, What, Where, When, Why, and  How (including any events leading up to the incident, if any). Attach statements if necessary.

If an injury occurred, describe where on body and description (Example: 3 inch cut on  back of upper left arm near shoulder).

SECTION 5: ACTION TAKEN 

Immediate action taken (Including treatment rendered, if applicable)  

When injured person or their parents refuse medical attention:

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I understand that ________________________________ is/am entitled to medical services, but I  do not feel it is necessary at this time.  

Injured party/parent: ________________________ 

Date: ________________  

Signature: ______________________________

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SECTION 6: VEHICLE/PROPERTY DAMAGE 

SECTION 7: PREVENTIVE ACTION/PLAN 

Name / Signature of reporting person / Date

Name: __________________________________

Date: _________________

Signature: _______________________________

SECTION 8: MANAGEMENT FOLLOWUP AND CORRECTIVE PLAN