ORANGE COUNTY 4-H INCIDENT REPORT FORM

How to file an Incident Report

  1. Use this form to report all non-medical incidents that pose health and safety concerns or potential violations of California 4-H Youth Development Program Core Values or 4-H member/adult volunteer Codes of Conduct.
  2. Complete all sections of this form. Incomplete information may not be useful to the 4-H Youth Development Program Staff.
  3. Give the completed forms to your local Community Club leader, in instances where that is not possible, or a 4-H Community Club leader is involved in the incident, mail this form to the Orange County 4-H Office, 1045 Arlington Drive, Costa Mesa, CA 92626. Keep a copy of this Incident Report Form for your records.
  4. Use the back of this form to briefly describe the incident you are reporting. Be sure to sign the report.
  5. All relevant information must be reported to the 4-H Program staff. This information will be used by staff to conduct an inquiry into the incident, and to assist the health and safety, core values or code of conduct concerns.

Person Filing the Report

Name_______________________________________________________________________________

Address______________________________________________________________________________

Phone Number _______________________________________________________________________

4-H Club_____________________________________________________________________________

Information Regarding the Incident

Date and Time of Incident _____________________________________________________________

Location __________________________________________________________________________

Name of 4-H Activity ________________________________________________________________

Adult 4-H Event Supervisor____________________________________________________________

Was anyone physically injured during the incident _______ yes _______ no

(If YES, was a 4-H accident claim form completed? _______ yes _______ no

Name of individuals involved in incident: 4-H Member/Volunteer Other Person 4-H Member or
Volunteer		 Other Person
     
     
     
     
Were there other witnesses to this incident? 

(If YES please list names below)
Individuals who witnessed the incident: 4-H Member/Volunteer Other Person

 _______ yes _______ no
     
     
     
     

Narrative
Please briefly describe what happened in the space below. Use additional paper, if necessary.

 

 

 

 

 

 

 

 

 

I certify that the information contained in this 4-H Incident Report is true to the best of my knowledge.

 

Signature ____________________________________________ Date____________________________