Complete this form for significant positive or negative incidents that occurs at practice or game throughout the season. This information will only be shared with Catholic Charities staff and Parish/School leadership as needed.

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* 1. Service Site Name (Facility/Parish/Field/Park/etc.)

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* 2. City of Service Site

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* 3. Location in facility (gym/locker room/field/etc.)

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* 4. Date and Time of Incident

Date & Time

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* 6. Team #1 Involved

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* 7. Team #2 Involved

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* 8. Person #1 Involved

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* 9. Person #2 Involved

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* 10. Person #3 Involved

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* 11. Check Incident Type:

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* 12. Write a brief description of the incident:

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* 13. Information on Person Competing the Form

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* 14. The incident was already communicated to:

T