Policy Violation Form

This form should be used to document any time a volunteer has violated a policy outlined in the Child and Youth Safety Policies. This information is kept confidential and used only for the purpose of tracking if a volunteer has multiple violations of a policy that may jeopardize the safety and/or mission of Children's and Youth Ministry.

Your name *

Last name

Email address *

Name of Volunteer(s) Involved: *

Description of what happened, including which policy was violated: *

Name and Contact Information of Witness(es): *

Is this the first time this volunteer has violated this policy? *

Yes

Yes, but this volunteer has been spoken to about a different policy before

No, this volunteer has been spoken to about this policy before

I don't know

What action has been taken as a result of this incident? *

Children's Ministry Coordinator notified

Youth Ministry Coordinator notified

Met with volunteer to review the policy, discuss why violation occurred, and make a plan to prevent further occurrences

Volunteer temporarily removed from position while incident is investigated

Additional documentation (i.e. Injury Repory Form, Suspected Abuse Form) completed

Met with Session or pastor

Other

Please use this field to enter any other pertinent information, if needed:

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Grace Church
office@gracechurchpca.com
5854458225

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