MASSACHUSETTS 4‐H INCIDENT REPORT In the event of a serious situation requiring immediate intervention/assistance call 911 and then promptly telephone your local Massachusetts 4‐H Extension Educator. If unable to reach that person, then call Sherrie Guyott, Program Director at: 508‐668‐9793 (day). Incidents after business hours or on the weekend, contact your local 4‐H office on the next business day. Please complete this Incident Report immediately after: Witnessing or learning about any situation that threatens the safety or wellness of club members, volunteers, staff or outside participants during 4‐H activities. If you have any question or doubt about whether to file this report or not, err on the side of caution and complete it. You may file an incident report as a result of your direct observation of the incident or information relayed to you by others. By signing this incident report, you agree to keep confidential the personal matters and information contained herein, and will not discuss the incident with anyone else. 1. BACKGROUND A. Person filing report_____________________________________________________________________ 4‐H title (Volunteer, parent, etc.) ____________________________ Cell number _________________ Email address_________________________________________________________________________ I witnessed the incident. Yes No The incident was reported to me by a third party. Yes No B. Name(s) of any volunteer, staff, program participant, member or, in the case of club members, age(s), involved in the incident: ___________________________________________________________________________________ ___________________________________________________________________________________
___________________________________________________________________________________ C. Names of individual(s) who sustained an injury, if applicable, and age(s) of youth: ____________________________________________________________________________________ ____________________________________________________________________________________ D. Date and time of incident: _______________ Location of incident____________________________ E. Name of 4‐H Program/Event:_____________________________________________________________ Page1of2
MASSACHUSETTS 4‐H INCIDENT REPORT
2. PROVIDE A BRIEF DESCRIPTION OF INCIDENT AND ADDRESS EACH OF THE ITEMS BELOW. Provide this information on a separate sheet(s) of paper and attach to this form. a.
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A brief description of the incident, accident or issue: Who responded, when, and what was the nature of the response: The affected party(ies)’ account of the incident: Action taken by yourself or others: Additional information that you think is important: Signature of Submitter Date FOR INTERNAL USE BY THE 4‐H YOUTH DEVELOPMENT PROGRAM
Local MA 4‐H Educator: ____________________________________________________________________ Date, time and notification method (fax, email or mail) of this report to the local 4‐H office: ________________________________________________________________________________________ Page2of2forms/2012IncidentReportfinal
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