ACCIDENT REPORT FORM

(Please print all information.)

Date of accident: Time of accident:

Name of reporter: Phone:

Name of child/youth injured: Age:

Address of child/youth:

Location of accident:

Parent or guardian:

Name of person(s) who witnessed the accident:

Name: Phone:

Name: Phone:

Name: Phone:

Describe accident:

This is a sample form. It needs to be modified to meet the specific needs of your congregation. For information
about creating policies and procedures for the safety of children and youth, please see Safe Sanctuaries or Safe
Sanctuaries for Youth published by Discipleship Resources.

© 1998 Discipleship Resources

Permission is given to reproduce this form for churches who have purchased Safe Sanctuaries.