Entered By (You, the person entering the report)

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Name & Contact Information	♦ First Name/Given Name ♦ Last Name/Surname ♦ WV/VF Job Title or Role ♦ Phone Number Include the area code, extension, and/or dialing codes if applicable. ♦ Email (Format: username@domain.com) ♦ Your Office Location (Select One) ♦ Your Office Type (Select One)

Incident Issue Selection (What kind of incident are you reporting?)

	Incidents can be simple and one-dimensional, or complex with more than one issue type. Select one primary incident issue type below and additional issue types as necessary.

	Add Issue Add Issue

Issue Type	♦ Is this issue being reported an Event, an Allegation or a Context Event / Near Miss? Actual Incident/Event Allegation Context Event / Near Miss (for use by Security only) (Select One)

Incident Level	♦ Identify the Incident Level below. Code Red / Safeguarding L3 Code Yellow / Safeguarding L2 Code Green / Safeguarding L1 (Select One)

Deaths/Injuries

Deaths/Injuries	♦ Were there any Deaths or Injuries involved? Death(s) WV Staff Non-Staff Adults Sponsored Children Non-sponsored Children Major Injury(ies) WV Staff Non-Staff Adults Sponsored Children Non-sponsored Children Minor Injury(ies) WV Staff Non-Staff Adults Sponsored Children Non-sponsored Children None

Incident Details

Incident Date & Time	♦ Approximate Date of Incident (Format: mm/dd/yyyy) Approximate Time (if known) (Select One of Each) Date of Discovery (Format: mm/dd/yyyy)

Incident Location	♦ Address GPS Coordinates (if known) (Example:45.4177871,-122.738962) LatitudeLongitude ADP/AP/MFI/Response area ♦ Country (Select One)

What Happened	♦ Please provide a narrative description of what happened. There will be an opportunity to attach any related documents directly after you click Submit, below. Note: Do not include child or adult beneficiary's real name. (Do not use the child's real name.)

Initial Actions	Clear All ♦ Initial actions taken. (Select all that apply, only one selection is required) Not Applicable Medical Assessment/Treatment Notification of Authorities Internal Investigation Individual(s) Arrested Disciplinary Action/Administrative Leave SOS/Medical Evacuation Fleet Accident Report Form Donor/Support Office/Grantor Identified Name: Other ♦ Define “Other”: Staff Care… Type of Intervention (Select all that apply.) Basic information package Distance Support Family Support Follow up Group Intervention Pastoral Crisis Intervention Post Deployment Debriefing Referral SAFER-R Staff Care Assessment Strategic Response Suicide Intervention Other

Initial Actions

Disaster Management	Did this incident take place in a Disaster Management response? HEA response Food Assistance response None (Select One)

Child Protection

Children	♦ Were any children involved in this incident? Yes No (Select One)

All People Involved

People	♦ Were any additional people involved in this incident? Yes No (Select One)

Assets

Assets	♦ Were there any related World Vision/VisionFund assets or World Vision/VisionFund vehicles/motorcycles involved in this incident? Yes No (Select One)

	Total Loss: $0.00

Outside Agencies Involvement (i.e. Law Enforcement, Insurance Companies, etc.)

Outside Agencies	♦ Were any authorities or outside agencies contacted/involved in this incident? Yes No (Select One)

Submit

	When you submit this report, you will be issued a Report Key. You will need this Report Key to upload documents or view your report at a later time. Please write the Report Key down in a secure and private place. Your report key cannot be recovered or reset once this report has been submitted. Using your Report Key, you can "Follow-Up" on this report by returning to this form and clicking on the “Follow-Up” link at the top of the page. Follow-Up will allow you to: Upload documents Respond to follow-up questions/comments Provide additional information about any of the people or assets, including World Vision vehicles, involved in this incident. To facilitate ongoing discussions related to incidents you submit, you will also be provided a Confirmation Number that will be stored in the Case Management system. You can use the Confirmation Number when speaking with your regional case managers about this incident. Print a copy of this completed report before clicking submit.

When you submit this report, you will be issued a Report Key. You will need this Report Key to upload documents or view your report at a later time. Please write the Report Key down in a secure and private place. Your report key cannot be recovered or reset once this report has been submitted.

Using your Report Key, you can "Follow-Up" on this report by returning to this form and clicking on the “Follow-Up” link at the top of the page.

Follow-Up will allow you to:

Upload documents
Respond to follow-up questions/comments
Provide additional information about any of the people or assets, including World Vision vehicles, involved in this incident.

To facilitate ongoing discussions related to incidents you submit, you will also be provided a Confirmation Number that will be stored in the Case Management system. You can use the Confirmation Number when speaking with your regional case managers about this incident.

Print a copy of this completed report before clicking submit.

Incident Report Form

Statement of Purpose