Child Pickup Incident Report Form
Report and document incidents related to the pickup or release of a child from care. Please complete all fields for accurate recordkeeping.
Date and Time of Incident
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Child's Full Name
*
First Name
Last Name
Staff Member Reporting
*
Type of Incident
*
Please Select
Unauthorized Pickup Attempt
Late Pickup
Early Release
Dispute at Pickup
Incorrect Pickup Person
Other
Person(s) Involved in Pickup/Release (Name and Relationship to Child)
*
Method of Pickup/Release
*
Please Select
Parent/Guardian
Authorized Pickup Person
Unauthorized Individual
Other
Description of Incident
*
Action Taken / Follow-Up Required
*
Witnesses (Name and Contact Information)
Submit Incident Report
Should be Empty: