RI Incident Report Form – Rocky Mountain Rotary Youth Exchange

Skip to content

Rocky Mountain Rotary Youth Exchange

Home
Programs
- Long Term Exchange
- Short Term Exchange
Students
Parents
- Host Parents
- Parents of Students
Rotarians
Resources
Contact

Search for:

Search

Home
Reports
RI Incident Report Form

Rotarian: File An Incident Report

File this report if there has been a medical or behavioral incident with an exchange student.

If you are a student, please file the student incident report form

Use the form below to file an incident report. In the case of an immediate emergency, please phone 911. You may also reach the Department of State (DOS) Emergency Hotline by phoning 1-866-283-9090 or by e-mailing to [email protected].

RI Youth Protection Incident Report

Name of person reporting*
First Last
Student's Information
Student's Name*
First Last
Student's Date of Birth*
MM slash DD slash YYYY
Home Country*
Host Club*
Sponsor/Home District*
Sponsor/Home Club Number*
Current Host Family*
First Last
Current Host Family Address*
Street Address Address Line 2 City State ZIP Code
Current Host Family Phone*
Alleged Offender Information
There were other parties involved*
- Yes
- No
If student is ill, select no
Alleged Offender Name*
First Last
Relationship to the student*
Title/Role (if applicable)*
if none, indicate ‘n/a’
Club name (if Rotarian)*
if the person is not a Rotarian, indicate ‘n/a’
Other Parties Involved, including contact information*
Incident Summary
Date of Incident*
MM slash DD slash YYYY
Time of incident*

: Hours

Minutes

AM/PM
Location of Incident*
Street Address Address Line 2 City State ZIP Code
Summary of Incident*
Please provide details of the incident
Action Taken
Action Taken*
Is the youth currently in a safe place?*
- Yes
- No
Please list all individuals or organizations that have been informed of the alleged incident to date*
(Example: districts, clubs, youth participant’s legal guardians, district governor, youth protection officer, etc)
Has the alleged incident been reported to local law enforcement? If not, why?*
- Yes
- No
- N/A Health Incident
Additional Information regarding reporting incident to law enforcement*
Is local law enforcement investigating the allegation, or have any official charges been filed? If so, please describe:*
- Yes
- No
- N/A Health Incident
Is local law enforcement investigating the allegation, or have any official charges been filed? If so, please describe:
Law enforcement Involvement*
Is local law enforcement investigating the allegation, or have any official charges been filed? If so, please describe:
Have any support services been offered to the youth? If so, please describe the service/provider:*
- Yes
- No
Describe support service/providers*
Future Steps*
Provide details on any future action that you/your organization plan to take regarding this allegation
Have you received any media inquiries regarding the allegation? If so, please describe:*
- Yes
- No
Media Inquires*

Δ

Join RMRYE on Facebook

facebook

Rotarian: File An Incident Report

Use the form below to file an incident report. In the case of an immediate emergency, please phone 911. You may also reach the Department of State (DOS) Emergency Hotline by phoning 1-866-283-9090 or by e-mailing to [email protected].

RI Youth Protection Incident Report

Student's Information

Alleged Offender Information

Incident Summary

Action Taken