Incident Report Form

Incident Details
Description of Incident*
Location, activity, step-by-step sequence of events.
What, if any, unsafe conditions or behaviors contributed to the incident?
How could the incident have been prevented?*
What actions were taken to address the incident?*
What procedures were followed in response to this incident and who completed the procedure? (Add as many as apply)

CPS Reporting
Have you reported your suspicions of abuse or neglect to Child Protective Services?*

YesNo
What was the name of the person you spoke to?*
What was the case number assigned to your report?*

Property Damage
Property damaged in the incident
Extent of the damage
Non-GSWW Property Owner's Name
Phone Number
Please enter a valid phone number.
Property Owner's Insurance Carrier
Phone Number
Please enter a valid phone number.

Law Enforcement Interactions
Was a participant and/or GS member arrested or detained from this interaction?

YesNo
What was the name of the individual?
If known, where will the individual be taken?
Badge number(s) of law enforcement agent(s) involved

Attachments
If you have pictures or copies of any warrants presented / items seized, please attach them below.
Upload any relevent pictures, documentation related to the incident (Optional)

Cancelof
Attach completed incident form*

Cancelof
Because this involved injury or illness at a girl scout property, please attach the health history forms for the affected individual(s)*

Cancelof

Submitter Details
Please use this space for any additional information you'd like Girl Scouts of Westen Washington to know about the incident.
Submitted by
Name of individual submitting this report
Email
example@example.com
Phone Number
Please enter a valid phone number.
Signature*

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