Incident Report Form
Incident Report Form
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Incident Report FormThis form is to be completed whenever a minor (involved in 4-H or any other Extension youth program), volunteer, or spectator who is participating in or attending an approved Purdue Extension event/activity is involved in an incident.
An incident includes accident/injury (which requires medical or dental attention), behavioral issues, abuse, neglect, etc.
Incident Reporting Steps for Club Leaders
Incident Reporting Steps for Club Leaders
WITHIN 24 HOURS:
Notify the 4-H Youth Development Extension Educator as soon as you have dealt with the immediate issue at hand.
From 8:00 AM to 4:00 PM, call the Extension Office at 260-724-5322 or email agjack@purdue.edu
After 4:00 PM, call/text 260-301-2103 or email agjack@purdue.edu
Complete the Incident Report Form above AND attach an additional paper which documents everything that happened in as much detail as possible involving the incident as well as what actions the volunteers took.
Please disregard the POMP-X questions as the Educator will supplement that information based on your club.
Email the completed report to agjack@purdue.edu and if further information is needed, you will be contacted.
If the issue requires police involvement or Child Protective Services (CPS), the volunteer/club leader should make those reports first priority. Then, taking the steps above immediately afterwards.
If you must make a report to CPS, please ask for a Case Number as it is helpful for reporting later on.
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