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Camp Victory Incident Report
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*
" indicates required fields
Name
This field is for validation purposes and should be left unchanged.
Section 1: Reporter Information
Name of Volunteer/Employee
*
First
Last
Phone
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Today's Date
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Time
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Hours
:
Minutes
AM
PM
AM/PM
Section 2: Incident Details
Date of Incident:
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Time of Incident:
*
Hours
:
Minutes
AM
PM
AM/PM
Location of Incident:
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(Campground area, room, building, event, etc.)
Type of Incident:
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Injury
Behavioral Issue
Medical Event
Removal from Activity
Property Damage
Other
If other, please explain.
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Section 3: Individual(s) Involved
Individual(s) Involved
*
– Click the + to add as many rows as needed.
– If the individual is an adult, just enter “Adult” in the age field.
– If the individual does not attend VLC, enter “Does not attend VLC” in the campus field.
Name:
Age (If Minor)
Role (Child, Student, Volunteer, or Staff)
Which campus do they attend? (If applicable)
Add
Remove
Section 4: Description of the Incident
Describe exactly what happened, including what was observed, the sequence of events, and any statements made. Use direct quotes if applicable. Do not include assumptions or conclusions.
Description:
*
Section 5: Immediate Response Taken
What actions were taken at the time?
*
Please select all that apply.
Separated individuals involved
Provided first aid
Contacted parent/guardian
Removed child from camp activity
Removed child from Camp Victory
Contacted ministry leader
Called 911
Other
If other, please explain.
*
Section 6: Parent/Guardian Notification
Was a parent/guardian notified?
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Yes
No
Name of person notified:
*
Method:
*
In person
Phone
Text
Time Notified:
*
Hours
:
Minutes
AM
PM
AM/PM
Section 7: Witnesses
(If applicable)
Witnesses
Name
Role
Add
Remove
Section 8: Follow-Up Required
Please select from the options below:
*
No follow-up needed
Medical follow-up
Behavioral review
Facility or safety review
Policy review
Other
If other, please explain.
*
Section 9: Reporter Affirmation
Reporter Affirmation
*
I affirm that this report is a true and accurate account of the incident as observed or reported to me, without speculation or personal opinion.
Signature
*
Today's Date:
*
Locations
Durant - Central Location
Atoka
Boswell
Broken Bow
Hugo
Stillwater
Sherman
Brownwood
Breckenridge Outreach
Woodland Park
Colorado Springs Outreach
