A PDF copy of this form can be downloaded by clicking here: DOWNLOAD

INCIDENT REPORT FORM

Date of Incident:

Time of Incident:

Type of Incident (Please Tick)

Medical

Accident (trips, slips, falls)

Property damage

Serious injuries

Robbery or violence

Death

Natual disaster

Others (please specify)Others (please specify)

Specific Location of Incident:

AFFECTED PERSON

Full Name:

Address:

Phone number:

Email:

REPORT

Reported by:

Position:

Reported To:

Position:

Date Reported:

Time:

Reported to Parent/Guardian/Next of Kin: (name):

Reported by:

Date:

TREATMENT INFORMATION

First Aid:

Yes

No

Doctor:

Yes

No

Ambulance:

Yes

No

DETAILS OF ALLEGED INJURY:

DESCRIPTION OF INCIDENT:

ACTION TAKEN:

WITNESS INFORMATION:

Witness:

Full Name:

Phone number:

Email:

PERSON COMPLETING THIS FORM:

Name:

Position:

Signed:

Date:

Confirmation

This completed form is to be kept with the Church Office records indefinitely.

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