Incident Report - First Cutlerville Christian Reformed Church

- ONLY COMPLETE THIS FORM ON CHROME AND FIREFOX BROWSERS

Date of the report: MM/DD/YY

First and Last Name of person completing the report:

Ministry where incident occurred:

Position of the staff member or volunteer:

When was the incident? (day, date, time of day)

Please describe the incident and who was involved: *

Where did the incident take place? *

Additional Information:

Names of witnesses (other people present)

Who did you contact about this incident? (Please contact the Ministry Coordinator for this ministry where incident occurred): * (1 required)

Children's Ministries Coordinator Student Ministries Coordinator Pastor Other

If you marked "other," please list their name:

When was this person notified?

Thank you for completing this form. Once the report is received and reviewed by the Discipleship Team, you may be contacted for further information.