2026 Incident/Accident Report

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Form completed by:(Required)

Email of staff member completing the form:(Required)

Email for the direct supervisor of staff member completeing the form:(Required)

Date Form Completed:(Required)

Date of Incident/Accident:(Required)

Time of Incident/Accident:(Required)

:

Program:(Required)

Location of Incident/Accident:(Required)

Incident/Accident Type:(Required)

Serious Incident of a Child/Customer/Guest

Serious Injury of a Child/Customer/Guest

Staff Accident

CEO Code of Conduct Violation

CEO Zero Tolerance Violation

Vehicle Accident

Was the staff member injured?(Required)

Yes

No

Unknown

Is the staff member seeking medical attention?(Required)

Yes

No

Unknown

Stating facts, describe the incident/accident.

Please include a description of the events that occurred prior that may have caused the incident or accident. Include names of the people involved, if applicable.(Required)

Names and Contact Information

Please include all staff, customers, children, individuals and witnesses involved.(Required)

Please upload any relevant documents to this incident:

Max. file size: 512 MB.

Including vehicle accident forms, observations forms, etc. ECS Managers do not need to include forms that are already in the Incident G:Drive.

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