Incident Report Form
Adelaide Hills Christian City Church Inc (C3 Church Adelaide Hills)
Contact Details of Person Completing this Form
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Contact Details of other people
Was anybody else directly involved?
*
Yes, other people were involved
No, no one else was involved
Details of other people directly involved OVER 18 years of age (Name, Age, Mobile)
*
Type N/A If not applicable
Details of other people directly involved UNDER 18 years of age if known (Name, Age, Mobile)
*
Type N/A If not applicable
Have the Parents/Caregivers been contacted?
Yes
No
Summary of contact with Parent/Caregiver (what was their response, do they understand what are the next steps, any follow up required etc).
Parent/Caregiver contact details
Name
First Name
Last Name
Email
example@example.com
Phone Number
Details of Incident
Church Location
*
Hahndorf
Henley Beach
Parkside
Playgroup (Hahndorf)
Dance Fusion
Church Department (kids, youth, connect, service etc.)
*
Date of Incident
*
-
Day
-
Month
Year
Date
Time of Incident
*
Nature of Incident (Physical, Disclosure, Emotional, Relationship, Suspicion of harm)
*
Location where incident occurred?
*
Details of what has occurred (please give as much information as possible)
*
Were there any witnesses? (Please provide details including Name, Contact details if known)
*
Type N/A if not applicable
If it is a physical injury identify the known areas of the injury (arm, leg, head etc)
*
Type N/A if not applicable
If first aid was provided, describe in detail the first aid given
*
Type N/A if not applicable
If emergency services attended such as Ambulance, Police or Fire, provide any details such as a police report number or contact details.
*
Type N/A if not applicable
Was there any Property Damaged, if so provide details including if the damage will pose a health and safety risk (i.e broken glass, unstable structure, exposed wires etc)
*
Type N/A if not applicable
Please provide any other information pertaining to this incident
Signature
Submit
Should be Empty: