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Incident/Injury Report

Volunteer Name*
First Last
Email*
Program Name*
Program Location*
Family Last Name*
Child's Name*
Date of Incident
Date Format: MM slash DD slash YYYY
Incident Type*
- Property Damage
- Injury - Accident
- Injury - Unknown Origin
- Injury - From Another Child
- Aggressive Act - Self
- Aggressive Act - Another Child
- Aggressive Act - Volunteer
- Concerning Behavior
- Other
Please describe:*
Incident Description*
Person(s) Who Observed the Incident/Injury:*
Explain what immediate action was taken:*
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