• Incident & Occurrence Report

  • Do not use this form for employee injuries or Workers’ Compensation claims. Contact Human Resources for the appropriate reporting process.

    Use this form to report incidents and occurrences involving non-employees, including volunteers, contractors, guests, ministry participants, Academy students, and guests.

    Address immediate safety and medical needs first. Call 911 when emergency assistance is needed. Complete this report as soon as reasonably possible and answer only the questions that apply.

  • Report Information

  • Date report completed*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of incident*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Approximate time of incident
  • Was the incident on or off church property?*
  • Crosspoint campus connected to the incident*

  • Type of Incident

  • Type of incident—select all that apply*

  • People Injured or Directly Affected

  • Complete this page only if one or more people were injured or directly affected by the incident. If no individual was affected, leave this page blank and select Next. 

    If more than two people were involved, identify the additional people in the Incident Description section.

    Provide the following information about Person 1, who was injured or directly affected by the incident.

  • Format: (000) 000-0000.
  • If the person is a minor, was a parent or legal guardian notified?

  • Provide the following information about Person 2, who was injured or directly affected by the incident. (Optional)

  • Format: (000) 000-0000.
  • If the person is a minor, was a parent or legal guardian notified?

  • Incident Description

  • Provide a factual, chronological account of the incident. Include what happened before, during, and immediately after the incident; relevant conditions or equipment; and any statements directly heard. Clearly distinguish between what you personally observed and what someone else reported to you. Do not assign blame, speculate, diagnose, or include personal opinions.

  • Medical and Emergency Response Information

  • If no one was injured, ill, or experiencing a medical emergency, select “No,” leave the remaining questions blank, and select Next.

  • Was anyone injured, ill, or experiencing a medical emergency?*
  • Was first aid or other assistance offered?
  • Was anyone transported for medical care?
  • This form documents observed or reported conditions only and is not a medical diagnosis.

  • Emergency Services Contacted

    Leave blank if no emergency services were contacted.
  • Emergency services contacted—select all that apply

  • Property Damage

  • Was any property damaged?*

  • Complete the remaining questions only if property was damaged.

  • Type of property damaged—select all that apply
  • Were photographs or video taken of the damage?

  • Witnesses

  • Complete this page only if someone directly saw or heard the incident. Do not list individuals who learned about the incident afterward. If more than two witnesses were present, identify the additional witnesses in the Incident Description section.

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Person Completing This Report

  • Format: (000) 000-0000.
  • I certify that the information provided in this report is accurate and complete to the best of my knowledge.
  • Confidentiality: This report is an internal, confidential church record. Share only with those responsible for incident response, investigation, insurance, legal compliance, pastoral care, or corrective action.
  • Should be Empty: