FGA First Aid Incident Report
Date of incident
*
-
Day
-
Month
Year
Date
Time of incident
*
Hour Minutes
AM
PM
AM/PM Option
Name of person completing this report
*
First Name
Last Name
Position
*
What ministry is this event part of? (Sunday Main Service, Kids, Fungus, 1830, Homegroups, Rejoice)
*
Sunday Main Service
Kids
Fungus
1830
Homegroup
Rejoice
Other
Phone Number
*
Format: 0000 000 000.
Email
*
example@example.com
Complete the following details about the person receiving first aid and the incident:
Name of person receiving first aid
*
First Name
Last Name
Gender
*
Female
Male
Age / Date of birth (if available)
*
Contact details of person receiving first aid (phone, email, address) (Parent/Guardian if under 18)
*
Is the person under 18?
*
Yes
No
If yes, have the parents been contacted?
Yes
No
Where did the incident occur (Multipurpose Room, Lobby, Carpark etc.)
*
Cause of incident
*
Activities of the person at the time of incident / Events leading up to incident
*
What is the Injury?
*
Time first aid provided
*
Hour Minutes
AM
PM
AM/PM Option
Description of first aid provided (Please also indicate if you used any consumables in the first aid kit)
*
Medical follow-up sought (Did you suggest any options for additional care?)
*
Indicate below the area of the injury
*
Further information (Are there any other comments you wish to make? Or do you have any suggestions for FGA to avoid the same incident from occurring again?)
*
Signature of First Aid Provider
*
Submit
Should be Empty: