Incident Report

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Type of Incident* This field is required.
Incident Report
Employee Injury Report
Property Damage Report
Security Incident Report
2
Reported By* This field is required.
First Name
Last Name
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Date and Time of Incident* This field is required.
4
Location of Incident* This field is required.
5
What is your location?* This field is required.please add an exact address as well as title.
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Ministry/Department Involved* This field is required.
Legacy Youth
Young Adults
Hills Kids
Worship
Production
Facilities
Safety
PK
Outreach
HWH
Parking
Summit
Ushers
First Impressions
Other
7
Type of Incident* This field is required.
Please Select
Please Select
Child Abuse/Neglect
Medical
Accident
Disturbance
Other
8
Provide a detailed timeline of the event(s) and include the extent of injury, if any. * This field is required.
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9
File Uploadattach any photos, videos, or documents pertaining to this incident.
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Select files to upload
Max. file size: 10.6MB
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10
How many people were involved?* This field is required.
11
If multiple, list names and ages of all parties here:* This field is required.
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Who was Involved?* This field is required.
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Individual's Full Name* This field is required.
First Name
Last Name
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
15
Membership Status* This field is required.
Regular Attendee
Visitor
Staff
Volunteer
Other
16
Date of Birth* This field is required.
Date
Year
Month
Day
17
Emergency Contact* This field is required.
Full Name
Relationship
Phone Number
18
Witnesses* This field is required.
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Parent or Guardian Name* This field is required.
First Name
Last Name
20
Parent/Guardian SignatureIf no parent or guardian is available at this time, please follow up with them regarding this incident ASAP.
21
Was an emergency response team notified?* This field is required.Police, Ambulance, Fire, Social Services, ETC.
YESNO
22
Was First Aid provided?* This field is required.
YESNO
23
Was an ambulance called?* This field is required.
YESNO
24
Was patient transported to the hospital?* This field is required.
YESNO
25
Was a police report filed?* This field is required.
YESNO
26
Was a Child Protective Services report filed?* This field is required.
YESNO
27
Is follow-up needed?* This field is required.
YESNO
28
Pastoral Care Needed?* This field is required.
YESNO
29
What type of follow up is needed?* This field is required.This could be prayer, care, further documentation, or something else.
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Injured Employee's Name* This field is required.
First Name
Last Name
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Employee Job Title* This field is required.
32
Supervisor's Name* This field is required.
First Name
Last Name
33
Was the Supervisor informed?* This field is required.
YESNO
34
Date and Time of Incident* This field is required.
35
Witnesses
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Location of Incident* This field is required.
37
Explain what happened* This field is required.
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38
Could anything have been done to prevent this? Please explain. * This field is required.
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39
Body Parts Affected* This field is required.
Arms/Hands
Legs/Feet
Head/Neck
Shoulders
Torso/midsection
Back/Spine
40
Have you had prior injuries to the affected area?* This field is required.
YESNO
41
Was a Doctor Consulted?* This field is required.
YESNO
42
Upload any photos, videos or documents relevent to this injury.
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Select files to upload
Max. file size: 10.6MB
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43
Employee Signature* This field is required.
44
What property was damaged?* This field is required.Please be specific. If this is a vehicle or piece of technology, list year/make/model.
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Please describe the damages:* This field is required.
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Describe what happened/how these damages occured:* This field is required.
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47
Upload all files pertaining to this incident. * This field is required.photos of damages, insurance cards, licenses, video of incident, etc.
Drag and drop files here
Select files to upload
Max. file size: 93.1TB
Browse Files
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48
Is this property owned by 7 Hills Church?* This field is required.
YESNO
49
Owner's information* This field is required.
Full Name
Please enter your phone
Please enter your email
50
Is this an emergency?* This field is required.
YESNO
51
Type of Security Incident* This field is required.
Theft
Suspicious Activity
Graffiti
Vandalism/Destruction of Property
Piggybacking/Tailgating
Person inside with no visitor badge
Lost & Found
Intruder
Homeless Encampment
Hostile Encounter
Unattended Package
Other
52
If Other, please explain:* This field is required.
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Were authorities notified?* This field is required.
YESNO
54
Detailed description of incident:* This field is required.
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55
Are you the primary contact for this incident?* This field is required.
YESNO
56
Primary contact information* This field is required.
Full Name
Please enter your phone
Please enter your email
Should be Empty: