Incident Report
Incident Date: * * Required Fields
Incident Time of Day: : AM PM * If incident location or incident type is 'Other'
please provide details in the box below:
Incident Location: *
Incident Type: * Threat Action *

Contact Information of Person Reporting Incident
First Name: * Last Name: *
Please enter either a contact phone number, e-mail address, or both *
Phone Number: Email:
Unit Affiliation:
Reporter Type: * If Reporter Type is 'Other', please provide details in the box below:

Who Did This Happen To? (if applicable)
Target One
First Name: Last Name:
Unit Affiliation:
  Gender: male female Age:
Target Two
First Name: Last Name:
Unit Affiliation:
  Gender: male female Age:
Target Three
First Name: Last Name:
Unit Affiliation:
  Gender: male female Age:

Who allegedly broke the rules/violated the policy?
Aggressor One
First Name: Last Name:
Unit Affiliation:
  Gender: male female Age:
Aggressor Two
First Name: Last Name:
Unit Affiliation:
  Gender: male female Age:
Aggressor Three
First Name: Last Name:
Unit Affiliation:
  Gender: male female Age:

Who witnessed the incident or has knowledge about what happened?
Witness/Bystander One
First Name: Last Name: Age:
Witness/Bystander is a: Scout       Volunteer       Scout Leader       Professional Scout
Parent      Neighbor        Other    If 'Other', please describe:
________________________________
Was There     Learned Afterwards
Witness/Bystander Two
First Name: Last Name: Age:
Witness/Bystander is a: Scout       Volunteer       Scout Leader       Professional Scout
Parent      Neighbor        Other    If 'Other', please describe:
________________________________
Was There     Learned Afterwards
Witness/Bystander Three
First Name: Last Name: Age:
Witness/Bystander is a: Scout       Volunteer       Scout Leader       Professional Scout
Parent      Neighbor        Other    If 'Other', please describe:
________________________________
Was There     Learned Afterwards

Please provide a detailed account of what happened. *

Lincoln Heritage Council

Copyright © 2009 - 2019 Connected Learning Network, Louisville KY