Reference ID (staff): __________________________ Date received: __________________
Reporter
Name:
Phone: __________________________ Email: ______________________________________
Preferred follow-up: ☐ Phone ☐ Text ☐ Email
Event
Event date: __________________ Time: ______________ Event / general area:
Type: ☐ Injury/illness ☐ Near miss ☐ Equipment ☐ Lost child ☐ Conduct/security ☐ Property ☐ Other
Person involved: ☐ Reporter ☐ Reporter's child ☐ Family member ☐ Witnessed event ☐ Other
First aid provided? ☐ Yes ☐ No ☐ Unsure Emergency services contacted? ☐ Yes ☐ No ☐ Unsure
What happened?
Immediate action taken
Adult witnesses who agreed to share contact information
Requested follow-up
☐ I confirm this report is accurate to the best of my knowledge.
Signature: __________________________________________ Date: __________________
Use a child's first name or team ID only. Do not record diagnoses, medications, insurance numbers, payment data or full medical records. Staff must secure this completed form immediately.