Incident Report Form
Nature of Incident (select all that apply)
*
Accident
Injury
Inappropriate Behaviour (Ex. Bullying, Discrimination, etc.)
Property / Equipment Damage
Hazard (Fire, Contaminant Exposure, etc)
Security Incident
Near Miss (Identified potential for injury or damage)
Other
Name of Individuals(s) involved
*
Contact Information of Individual(s) involved.*
(*Record for adults and minors who are not registered in church programs)
Age/Grade of Individual(s) involved (If minors are involved)
Nursery
Preschool / Kindergarten
Grade 1 - 3
Grade 4 - 6
Grade 7 - 9
Grade 10 - 12
Time of Incident
*
Hour Minutes
AM
PM
AM/PM Option
Date of Incident
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Incident
*
Personnel Present at Time of Incident
*
Description of Incident
*
What happened?
Course of Action Taken
*
If minors were involved, were Parents/Caregivers contacted?
Yes
No
N/A
Parent/Caregiver Response if contacted
Name of Person Filing the Incident Report
*
First Name
Last Name
Email Address of Person Filing the Incident Report
*
A copy of the incident report will be sent to this email address.
Signature of Person Filing the Incident Report
Name of Witness (Witness must be unrelated to the Personnel who is filing the report)
*
First Name
Last Name
Primary Contact Information of Witness
*
Email or Phone Number
Submit
Should be Empty: