Teen Court Incident Report
Date of Report _________________ Date of Incident ______________
Incident Party(s)
Name ________________________________ Age ______
Title ______________________ ID Number ___________
Location ______________________ Department ________________
Date of Membership _______________ Time as member (months) ______
Time in this position (months) ____________
Name ________________________________ Age ______
Title ______________________ ID Number ___________
Location ______________________ Department ________________
Date of Membership _______________ Time as member (months) ______
Time in this position (months) ____________
Date of Injury _____________________ Time of Injury ______
Name ________________________________ Age ______
Title ______________________ ID Number ___________
Location ______________________ Department ________________
Date of Membership _______________ Time as member (months) ______
Time in this position (months) ____________
Exact Location of incident
_____________________________________________________
Names of Witnesses
_________________________________________________________________________________________________________________________________________________________________________________________________________________
Remarks: Be specific:
__________________________________________________________________ ______________________________________________________________________________________________________________________________________________
Describe how incident occurred: (What was member doing? What duty or task?) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________
What happened that resulted in this incident?
___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________
What factors do you believe contributed to this incident? (Consider methods, procedures, environment, instructions, rules, inherent hazards, skill, experience, materials, and other factors.)
____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________
How could such an incident have been prevented or avoided?
___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________
The investigating Committee (People to be included in the accident investigation are listed below.)
1. Involved Member(s) ______________________________________
2. Immediate Supervisor ___________________________________
3. Teen Court Coordinator (or Rep.) _______________________________
4. Witnesses ____________________________________________
5. Teen Court Master _______________________________
6. Teen Court Advisor______________________________
7.Administrator (or Rep) _______________________________
Note: Report to be completed by immediate supervisor and turned in to the teen Court Coordinator no later than the end of the day following the incident.
PEOPLE TO BE INCLUDED IN INCIDENT INVESTIGATIONS:
The extent of the investigation will be left to the discretion of the administration.
Immediate and/or Final Investigation1. Involved Member(s) ______________________________________
2. Immediate Supervisor ___________________________________
3. Teen Court Coordinator (or Rep.) _______________________________
4. Witnesses ____________________________________________
5. Teen Court Master _______________________________
6. Teen Court Advisor______________________________
7.Administrator (or Rep) _______________________________
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