Incident Report Form
Details of Person Completing Form
Name of Person Completing Report
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
Relationship to Church
Member
Guest
Staff Member
Pastor
Other
Witness Details. (Please complete details of person who witnessed incident)
Name of Witness 1:
First Name
Last Name
Email
example@example.com
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Witness Details (Please complete details of person who witnessed incident)
Name of Witness 2:
First Name
Last Name
Email
example@example.com
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Incident Details (Please Provide Incident Details Below)
Please Provide Incident Details: Type of Report
Please Select
Hazard Report
Injury/Medical Report
Incident or Near Miss Report
Vulnerable Person Report
Incident Date & Time
-
Day
-
Month
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident (if applicable):
Please include room of Church if occured on Church Property
Details of Incident:
Please include description of incident here. Include as many details as possible.
Is this a WHS Notifiable Incident
*
Please Select
Yes
No
Not Sure
Tip: A WHS notifiable Incident includes: Death of a person, a serious injury or illness, or a dangerous incident that exposes someone to a serious risk (even if no one is injured).
Is this a Reportable Incident
*
Please Select
Yes
No
Not Sure
Tip: Is this a Mandatory Report or Reportable Conduct Incident.
If Yes Please Provide Detail of Report Made:
Please provide details if report made to Police, CYPS (Child Protection). Or if this fits reportable conduct please note Pastor notified
Person/s Involved Details
Details of Person/s Involved How was this person involved?
Please Select
Injured or Unwell Person
Vulnerable Person
Complainant
First Aider
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please describe injury/injury location/how this incident affected the person
Was Medical Advice Advised?
Yes
No
Not sure
Was ambulance called?
Yes
No
Not sure
If Yes to Above Provide Details:
Person/s Involved Details
Details of Person/s Involved How was this person involved?
Please Select
Injured or Unwell Person
Vulnerable Person
Complainant
First Aider
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please describe injury/injury location/how this incident affected the person above
Was Medical Advice Advised?
Yes
No
Not sure
Was ambulance called?
Yes
No
Not sure
If Yes to Above Provide Details:
Person/s Involved Details
Details of Person/s Involved - How was this person involved?
Please Select
Injured or Unwell Person
Vulnerable Person
Complainant
First Aider
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please describe injury/injury location/how this incident affected the person above
Was Medical Advice Advised?
Yes
No
Not sure
Was ambulance called?
Yes
No
Not sure
If Yes to Above Provide Details:
Please Complete Below If Property Was Damaged or Affected
Property Damaged
Please describe what happened briefly if property was damaged - include why
Has the cause of the incident been removed?
Yes
No
N/A
Not sure
Are there other follow-up steps you believe should be taken?
Yes
No
N/A
Not sure
Please list the steps should be taken:
Is there anything else you would like to add:
Signature:
Name of person who has completed this form
First Name
Last Name
Date
-
Day
-
Month
Year
Date
Please Sign and Click Submit Below
Submit Incident Report to Church Office
Should be Empty: