INCIDENT REPORT FORM
Form to be completed by the ministry leader and/ or church staff member who was at the incident / accident.
The form is to be completed and submitted within 48 hours of the incident/accident occurring.
NATURE OF THE OCCURRENCE
What was the nature of the occurrence?
Accident (Person injured)
Incident (Near miss / Dangerous occurrence)
Security Breach
PEOPLE INVOLVED
Sick / Injured / Involved Person's Details (1)
First Name
Last Name
Gender
Male
Female
Date of Birth
Mobile Number
Home Address
Person 1's Next of Kin
First Name
Last Name
Mobile Number
Home Address
Sick / Injured / Involved Person's Details (2)
First Name
Last Name
Gender
Male
Female
Date of Birth
Mobile Number
Home Address
Person 2's Next of Kin
First Name
Last Name
Mobile Number
Home Address
NOTIFICATION
Was Next of Kin notified?
Yes
No
Was First Aid administered?
Yes
No
Were Police / Fire / Ambulance notified?
Yes
No
Comments
DETAILS
Initial Occurrence Date
Report of Occurrence Date
Check the most applicable descriptors below:
Sickness
Injury
Fire
Vehicle Accident
Property Damage
Weather Event
Slip
Trip
Fall
Crush
Theft
Trespassing
Auditorium
Cafe/Bookstore
Playground
Court
Classroom
Field
School
Workshop
Printshop
Parking Lot
Bathroom
Offsite
Church Service
Impact Kids
Impact Youth
Young Adults
Chargekeepers
Other event
Initial Occurrence Time
Report of Occurrence Time
DESCRIPTION OF EVENTS
In the space below provide a detailed written description of the incident / injury / illness.
Include all those involved and any applicable timings.
Description:
YOUR DETAILS
Please fill in the details of the person completing this form:
First Name
Last Name
Mobile Number
Submit