Incident Report Form

Name of person who observed, or received a report of, alleged abuse or neglect:

Date/time/place of person’s observance or receipt of report:

Name of person who had initial conversation with the child, youth, or vulnerable adult concerning alleged abuse or neglect (hereinafter “Vulnerable”):

Date/time/place of initial conversation with the Vulnerable:

Vulnerable's Name

Vulnerable's Age

Vulnerable's Date of Birth (if known)

Vulnerable's Address (if known)

Parent/Guardian #1 Name

Parent/Guardian #1 Address (if different from Vulnerable's)

Parent/Guardian #2

Parent/Guardian #2 Address (if different from Vulnerable's)

Name and Address of any other individual responsible for the care of the Vulnerable

Present location of the Vulnerable

Name of person accused of abuse/neglect

Relationship of accused to Vulnerable

Paid Staff of Hunt's Church Hunt's Church Volunteer Family Member Other

If you marked "other," please specify:

Specific nature and extent of injury, abuse or failure to provide proper care of and attention to the vulnerable, and any information concerning possible previous abuse or neglect:

Any other information that might aid in establishing the cause of injury, assist identifying the individual(s) responsible for the abuse or neglect, or relate to the identification of risk: i.e., witnesses, signs of physical abuse.

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Report completed by:

By typing my name below, I am digitally signing this form.

Name

Date Completed

Description

This form collects information about observed or reported abuse, neglect, or harassment. If you have any questions about this form, please contact the pastor or chair of SPRC.

Incident Report Form

Description

Please Fix the Following