Reminders when completing Cove Church Confidential Incident From

Please, be as detailed as possible. Focus conversations on this specific incident. Live out The Cove Mission Statement and Values during this process. Also as much as possible, exercise grace and unconditional love. Always maintain confidentiality. If using a paper version of this form for notes please, remember to complete the electronic form on The Cove Safety Hub.

Select the Campus

Exact Location of Incident

Date of Incident

Today

Time of incident

Name of person involved in incident (First, Middle, Last)

Full address of person involved in incident

Telephone Number (cell/home) of person involved in incident

If under 18, The name of Parent or Guardian notified:

Who notified the Parent or Guardian? (please provide full name)

Name and Address of Medical Facility

Escort to Medical Facility- Full Name and Contact Information

Person filling out report name and contact phone number

Email of person submitting report

Was The Cove Notiifed

First Name, Last Name and Phone Number of others who may have observed the incident

Name of any injury body part, please be specific in description.

Incident Description: Who, What, When, Where

Electronic Signature of person filling out this form

This report of injury is for internal use only by Cove Church Pastors, Officers, Assigned Staff and Legal Counsel. It has been prepared at the request and direction of Cove Church Legal Counsel in anticipation of possible litigation and is subject to and protected by the attorney- client privilege.

Please include any preventative ideas

Corrective Action Discovery and Ideas