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Extension Network Sites > 4-H Youth Development Program > Resources for Youth Members > Incident Report Form

Incident Report Form

Please Note: To address a widespread security vulnerability, our forms are currently disabled. Please do not submit forms at this time. Attempting to submit a form will result in an error message. If you have questions, reach out to your county Extension office, or send us an email at washington.4h@wsu.edu. Thank you for your patience while we work on getting our forms restored.

4-H Incident Report

What county do you reside in? Please choose from the dropdown menu:

Name of 4-H Sponsored Event(Required)

Date(s) of Event:(Required)

Location of Event/Address:(Required)

Person involved in incident:

Name(Required)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth

Status at Event(Required)

Enrolled 4-H Member

Non-enrolled 4-H member

Active 4-H Leader

Parent

Public

What is your email address?

Phone

Date and Time of Incident

Date of Incident:(Required)

Time of Incident:

Type of Incident:(Required)

Behavioral

Accident

Illness

Other

Emergency reported to:

By way of:

Extension/Staff or Volunteer in charge at time of incident:(Required)

Role (Extension Staff, Volunteer or Parent)

Name of Parent/Guardian

Was the Parent notified?(Required)

Yes

N/A

Time

By whom?(Required)

Name of Emergency Contact:

Was Emergency Contact notified?

Yes

N/A

Date

Time

By whom?

Type of Medical Care Received(Required)

Adult(s) on the Scene?(Required)

Adult(s) Rendering aid?(Required)

Witness #1

Name(Required)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Where located at time of the incident?

Witness #2

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Where located at time of incident?

Witness #3

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Where located at time of incident?

Description of Incident:

1. Sequence of Activities: (e.g. at the beginning of the club meeting, during leisure time, after the workshop.) What led up to the incident?(Required)

2. Location: Where did the accident occur in the space? Where were the other participants/leaders? A diagram may be helpful and can be uploaded as a file.(Required)

File

Max. file size: 80 MB.

3. Exactly what was the person doing and how did the incident occur? What was going on? Who was involved?(Required)

4. What steps could have been taken to prevent the incident or minimize the impact of the incident?(Required)

5. Acton taken at the time of incident?(Required)

6. Action(s) taken as a follow-up to the incident (if applicable.)(Required)

Follow-up report needed?

Yes

Signatures: Person(s) completing all or part of the report?

Name #1

First Last

Signature #1

Date

Time

Name #2

First Last

Signature #2

Date

Time

4-H Faculty and/or Staff

Name

First Last

Signature

Time

Date

Phone