Incident Report Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Information about the IncidentDate and Time of the Incident *What Persons or Groups were Notified?Law EnforcementFire DepartmentEmergency Medical ServicesParent/GuardianOtherCheck all that applyOthers Notified *Location of the Incident *Identify Persons Directly Involved in the Incident *Please Identify the individuals involved directly in the incident. Include their full names, contact information (address, phone, email, etc.), and their relationship to FVUMC (student, member, employee, etc.).Description of the Incident *Please provide a clear, factual, and chronological account of the incident. Be as specific as possible. Include a step-by-step summary of events as they happened, the behavior and actions of all individuals involved, any specific words that were spoken, and any conditions that may have contributed to the incident (e.g., a wet floor, a broken piece of equipment).Identify Witnesses to the IncidentPlease provide the names, addresses, phone numbers, and email addresses that are known to you for any and all witnesses to the incident.Describe any and all Injuries SustainedPlease describe all injuries. For each injury, specify the part of the body affected and the nature of the injury (e.g., "deep cut on right index finger," "bruised left knee," "soreness in lower back").Was Medical Treatment Provided? *--- Select Choice ---YesNoRefusedI do not knowDescribe any and all Medical Treatment Provided *Please describe the treatment with particularity.Where was Medical Treatment Provided?On SiteUrgent CareEmergency RoomOtherCheck all that apply.Other Location of Medical Treatment *Submission InformationProvide Your Full Name What Certification of What is your Relationship with FVUMC?Ex: "Preschool Director", "Member", etc.Your Email Address *EmailConfirm EmailA copy of this report will be sent to the email address you provide here, as well as the Facilities Manager, Executive Director of Operations, and the Lead Pastor.Certification *By submitting this form, I certify that the contents of this report are true and accurate to the best of my knowledge, information, and belief, and I am submitting this form to report an incident and not for any improper purpose.Submit
