CHAPLAIN ACTIVITY REPORT
Please Complete As Soon As Possible Following Event
Unit No. & Name
*
Please Select
C1 Jim Dixon
C3 Bob Box
C4 Eddie Davis
C5 Jacqueline Eakins
C6 Jerry Bolander
C7 Dave Hadsell,
C8 Mark Jechura
C9 Jo Jones
C10 David Myers
C11 Terry Simmons
C12 Charles Walden
C14 Jeff Dixon
C15 Galen Pearcy
JC1 Peggy Arend
JC2 Mary Haynes
JC3 Chris Schaefer
Date of Event
*
/
Month
/
Day
Year
Choose Date
Type of Event
*
Please Select
Administrative Tasks
Ride-Along
CISM Event
Counseling
Death Notification
Fire
Jail Visit
Training
Unattended Death
Other-Please Explain in Detail Box
Agency other than BCSO?
24-HOUR TIME ONLY PLEASE!
Time Notified
24 HR. TIME ONLY
Time Arrived (10-97)
*
24 HR. TIME ONLY
Time Left (10-98)
*
24 HR. TIME ONLY
Details (Do not include counseling details)
Would you like to be contacted regarding this event?
Please Select
Yes
No
Response not required
Is Follow Up Necessary?
Please Select
Yes
No
Response not required
Submit
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