Incident Report | Booker T. Washington Center

Booker T. Washington Center

1720 Holland Street Erie, PA 16503 +1 814 453 5744

2026 BTWC Incident Report

Accidents, injuries, behavior, safety and other incidents

EMERGENCIES COME FIRST

If anyone is in danger or seriously hurt, call 911 now. If a child is missing, alert the staff on duty and search right away, then call 911. Complete this report after everyone is safe, the same day.

FOR VOLUNTEERS, VISITORS, PARENTS AND PARTNER STAFF

Use this form to report an accident, injury or other incident that happened at the Booker T. Washington Center or at a BTWC program. Your report goes privately to BTWC's directors. BTWC staff should use the BTWC Staff app instead.

1 Person Filing This Report

Name of Person Filing *

Your Connection to BTWC *

Phone *

BTWC Staff Member You Told (if any)

2 When and Where

Date of Incident *

Time of Incident *

Location *

Other Location / Exact Spot

Room, area or address if off-site

Program or Activity at the Time

For example: homework time, gym, bus route, field trip, lunch

4 What Happened

Write only the facts, in the order they happened: who, what, where and when. Use people's exact words in quotation marks when you can. Do not guess or give opinions.

What Was Happening Right Before

Describe the Incident in Detail *

5 Persons Involved

Everyone directly involved, including the injured person, any child, parent, staff member or visitor.

PERSON 1

Name

Role

Age (participants)

Phone / Parent Contact

Injured?

PERSON 2

Name

Role

Age (participants)

Phone / Parent Contact

Injured?

6 Witnesses

Anyone who saw or heard what happened. Ask each witness to write a short statement if they can.

WITNESS 1

Name

Role

Phone / Email

Written Statement

WITNESS 2

Name

Role

Phone / Email

Written Statement

7 Injury, Illness and First Aid

Complete if anyone was hurt or became ill. Otherwise choose "No one was hurt".

8 Notifications

Parent / Guardian Notified? *

Yes No Not applicable

Police Called? *

No Yes

ChildLine Report Made? *

Not applicable Yes Not yet

9 Actions Taken and Follow-Up

Actions Taken Right Away *

For example: separated the students, gave first aid, called the parent, searched the building, removed the hazard.

Follow-Up Recommended

10 Certification and Signature

I certify that this report is true and complete to the best of my knowledge. I understand that it is an official Booker T. Washington Center record, and that knowingly giving false information may lead to discipline or removal from BTWC programs and property.

Type Your Full Name *

Date

November 2, 2026

Sign Here *

Sign with your finger or mouse. Clear

Your report goes privately to BTWC's directors.

Booker T. Washington Center · Confidential incident report. Reports are read only by BTWC's supervisors and directors.

2026 BTWC Incident Report

1 Person Filing This Report

2 When and Where

3 Type of Incident

4 What Happened

5 Persons Involved

6 Witnesses

7 Injury, Illness and First Aid

8 Notifications

9 Actions Taken and Follow-Up

10 Certification and Signature