Incident/accident Report Form printable pdf download

CHURCH OF THE ROCK INCIDENT/ACCIDENT REPORT FORM

The following information must be completed each time an individual is injured or is involved in an incident of concern.

Senior Leadership must be informed of all the details of the said incident. Please fill in the questions below as completely

as possible.

Location the incident occurred: ______________________________

Date of Incident: _____________________________

Time of Incident: ______________________________________

Person(s) Involved in Incident:

Others Observing Incident:

____________________________________

______________________________________

____________________________________

______________________________________

____________________________________

______________________________________

Give a brief description of the incident/accident (including who did what to whom):

_________________________________________________________________________________________________

Was it necessary to administer first aid?

Yes

Please explain the type of care that was given:

_________________________________________________________________________________________________

Did any recognized medical personnel (doctor, nurse etc) attend to the injured person?

Yes

If yes, please give name and phone number

(if possible)_______________________________________________________________________________________

Was the incident reported to: Senior Leadership

Police

File #___________________________

Please indicate the condition of the affected person in the incident:

Bruising, no blood

Blood

Hurt, no visible signs

Other: ___________________________________

Please ensure that you:

1. Notify Senior Leadership of the above incident; and

2. Place the completed form in a sealed envelope in the Administrators/Human Resources mailbox;

3. Follow up if necessary.

Signature: _____________________________________________________

Please print name:_______________________________________________

Phone #:_______________________________________________________

Incident/accident Report Form