Incident Report Form

Thank you for using the incident reporting form. This helps us with record keeping and taking action on any safety matter that should be brought to our attention.

All incidents should be:

Raised to Team Leader
Reported via this form
Escalated to the Pastoral Team & Safe Ministry Contact immediately in serious cases

In cases of safety concern and care for others, please complete the below to the best of your ability and an investigation will take place.

When completing this form, the emphasis must be on the facts and observations that are available. Please avoid all speculation.

This form should be used for the following rare events:

Injuries and medical incidents (slips, cuts, allergic reactions, etc.)
Damage to property (Breaking of furniture or electronic equipment)
Other incidents of safety concern (incidents of hazards in church, suspected concern for a vulnerable person, etc.)

This form will take you approximately 5-10 minutes to complete.

Please remember that ALL safey incidents should be raised with your direct leader(s) before and in addition to completing this form.

Nature of incident *

Incident details

Date of incident *

Time of incident (please include AM/PM) *

Incident address and specific location *

Tip: Please provide the address (including the postcode) of the incident. And provide the specific location (e.g. Room 4 of Level 2)

Were any people involved in this incident? *

Yes, and I am able to identify them

Yes, but I am not able to identify them

Description of the incident *

Tip: Please provide as much detail as possible, for instance: the events that led to the incident; the activities occurring when the incident happened; the overall action, exposure or event that best describes the circumstances that resulted in the injury, illness, fatality or dangerous incident; the object, substance or circumstance which was directly involved in inflicting the injury, illness, death or dangerous incident; the name and type of any furniture, device or substance involved. Was anyone else involved? Was electricity or electrical equipment involved?