Fresh Start Church Incident Report

Complete this report under any of the following situations:

A. Someone becomes ill or receives an injury that requires First Aid or medical treatment while in your care.
B. Someone receives a bump or blow to the head or other visible injury regardless of treatment.
C. Someone is transported by ambulance from your facility.
D. An unusual or unexpected incident occurs that jeopardizes an individual or child's safety, such as a child left unattended, there is a vehicle accident (with or without injuries), or someone is exposed to a threatening person or situation.
E. There is an allegation or reasonable suspicion of abuse of a child. Important: NJ requires any suspected child abuse to be reported immediately to DYFS.
Date

Be as specific as possible. Include building and room/environment if applicable.

Check all that apply.

No files currently selected

Add up to 5 files. Maximum file size 10 MB.

    This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.