Current Incident Report for Programs and Camps for Minors Complete This form is for the NCCU community and people affiliated with any youth programs and/or camps on the campus of NCCU to complete if they witness an incident with a minor that is in attendance. Name of Program Name of Program Director Name of Child Age of Child Name of Child’s Parent or Guardian Your Contact Information Your Full Name Your Email Address Your Phone Number Nature of This Report Child abuse Child neglect Injury or illness Sexual incident Other type of incident Enter here Please provide a detailed description of the incident or concern using specific, objective language (who, what, where, when, why and how): Date and Time of Incident Date and Time of Incident: Date Date and Time of Incident: Time Location of Incident Were the minor’s parents contacted? Yes No Was the incident reported to any other entity? Yes No If yes, please indicate to whom the report was made: Supporting Documentation Photos, video, email and other supporting documents may be attached below. The maximum total size of all uploads is 1 GB. CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Leave this field blank
