Fillable Youth Protection/membership Incident Information Form printable pdf download

CONFIDENTIAL

Youth Protection/Membership

Incident Information Form

(Allegations of abuse, violations of BSA guidelines or policies, inappropriate behavior by a Scout/Scout leader/parent/other)

Please forward this Incident Information Form and supportive documentation to the Scout executive as soon

as practical.

Submitting this form to the Scout executive does not eliminate/discharge your responsibility to immediately stop the

behavior at issue and to protect the youth, nor your mandatory reporting of child abuse obligations imposed by state

law or the BSA’s mandatory reporting of child abuse policy.

Incident date: ______________________________ Date incident reported to council: ________________________________

Council/BSA location where incident occurred (if applicable): ____________________________________________________

Incident address: ___________________________________________________________________________________________

City

State

Zip



Report type:

Suspicion/allegation of abuse

BSA policy or guideline violation(s)



Other inappropriate behavior by a Scout/Scout leader/parent/other

Details of incident: What alleged victim/target/injured party said, what reporter observed/was told, similar or past

incidents involving the victim(s)/target(s)/injured party (parties) or violator(s)/offenders(s), etc.

____________________________________________________________________________________________________________

PERSON FILLING OUT THIS FORM: _________________________________________________________________________

Scouting position: ___________________________________________________________________________________________

Address: ___________________________________________________________________________________________________

City: _____________________________________________ State: ____________________________ Zip:___________________

Phone(s): Primary ________________________________________ Alternate _________________________________________

Email: __________________________________________________________

PERSON WHO REPORTED THIS INCIDENT: _________________________________________________________________