Incident Report

Incident Report

Thank you for helping us maintain a high standard of health and safety at The Street Church.
Your Details

Please complete these questions as they relate to you, the reporter. We'll ask for details about any affected parties in a later section.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

PrefixPhone Number

Incident Particulars
When did the incident happen?*

YearMonthDay
Hour MinutesAM/PM Option
Church 'Location'*
Does this incident relate to a particular church 'Location'?
Venue/Address*
Where did the incident happen?
Ministry/Area*
Please pick the ministry or area that best relates to this incident.

Incident Details and Follow-Up
Incident Summary Statement*
Please provide a short one or two-sentence summary of the incident. You will be asked for more details in the following questions.
Incident Type

Please review the following incident types and consider which applies best to this incident.
- Concern: Observing a practice or condition that might lead to a problem, even though no incident has occurred yet. Example: Feeling uneasy about using a steep side-stage ladder to access storage.
- Hazard: An identified risk or danger. Example: Loose cables in a walkway.
- Illness: Any physical or mental health condition adversely affected or caused by activities, events, or environments related to the church. Example: Food poisoning from a church event meal or emotional distress caused by harassment or bullying within a church context.
- Injury: Physical harm resulting from an incident during a church activity or on church property. Example: A child falling and bruising their knee.
- Near Miss: A close call with no injury or damage, but where an incident could have been caused under slightly different conditions. Example: A heavy object almost falling off a shelf but being caught in time.
- Property Issue: Any incident or discovered issue relating to property, including damage, breakage, unauthorised occupancy, or other property-related problems. Example: A broken window from a sports activity.
- Security Issue: Any event or discovered issue which indicates compromised safety or security of individuals or property within the church environment, including breaches of security protocols, theft, vandalism, or unauthorised access. Example: Disruptive behaviour or threats made during church activities or cybersecurity breaches, such as hacking into church computers or networks.
- Unsafe Act: Any action or behaviour that disregards established safety protocols and creates a risk of injury, illness, or damage. These actions are often careless, negligent, or involve unnecessary risks. Example: Using a ladder improperly, such as standing on the top rung.
Incident Type*
Incident Severity

We determine severity by assessing the degree of actual or likely potential harm from the incident, near miss, or policy breach, considering both physical and mental health impacts.

Major:
- Actual Harm: An injury or condition requiring hospital admission or time off work, such as severe fractures, major burns, serious internal injuries, or severe mental health crises necessitating psychiatric intervention.
- Potential Harm: Incidents with a high likelihood of causing severe injury, death, or significant mental health deterioration, such as falls from heights, major vehicle accidents, exposure to hazardous substances in large quantities, or traumatic events likely to cause long-term psychological harm.
Moderate:
- Actual Harm: Injuries requiring medical attention, such as fractures, lacerations needing stitches, or concussions necessitating a visit to the doctor or emergency room, or moderate mental health issues requiring professional counselling.
- Potential Harm: Incidents with the potential to cause injuries needing medical attention but not necessarily hospitalisation, such as slips and falls on level surfaces, minor vehicle accidents, exposure to moderate hazards, or events likely to cause temporary psychological distress.
Minor:
- Actual Harm: Minor injuries that may require basic first aid, like minor cuts, bruises, sprains that can be treated onsite, or minor mental health concerns that can be managed with brief intervention.
- Potential Harm: Incidents with the potential for minor injuries that can be easily mitigated, such as tripping over objects, minor vehicle scratches, exposure to low-risk hazards, or minor events that could cause short-term psychological discomfort.
Negligible:
- Actual Harm: No physical injuries or harm incurred during the incident or negligible mental health impact.
- Potential Harm: Incidents with negligible hazards or near misses that pose minimal risk of harm, such as minor spills that are quickly cleaned up, minor equipment malfunctions without injury, minor protocol deviations promptly corrected, or events with minimal potential for psychological impact.
Incident Severity*
Who was involved?*
Please list the full names and roles of individuals involved in the incident (e.g., volunteers, staff members). Include contact details if available.
What happened?*
Please provide a detailed description of what occurred during the incident. Include any relevant actions, events, or circumstances leading up to and following the incident.
What immediate actions were taken?*
Please describe any immediate actions or interventions taken in response to the incident. Include steps taken to address the situation and prevent further harm.
Was first aid administered?*

YesNo
What follow-up do you think could be beneficial?*
Please provide any suggestions or recommendations for follow-up actions or improvements related to the incident. Your input helps us address concerns and prevent similar incidents in the future.
Is there any other information which could be helpful?
Please include any additional details or information that you think would be helpful for understanding or addressing the incident.
Upload supporting material

Please upload any photos or visual evidence related to the incident. Images can provide valuable context and assist in the investigation process.
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Privacy Statement

By completing this form, you agree to the collection of your personal information and its use by staff and volunteers at The Street Church and for it to be updated when you participate in any ministry or provide us with updated or new information. It may be used to contact you, assist with the planning and operation of ministries, record your participation in ministries or help us provide pastoral care to you and your family. For more information, see www.thestreet.org.nz/privacy
Should be Empty:

Your Details

Incident Particulars

Incident Details and Follow-Up

Incident Severity

Major:

Moderate:

Minor:

Negligible: