Medical Incident Report

ADVERTISEMENT

MEDICAL INCIDENT REPORT
INSTRUCTIONS: Please complete this Form, and as appropriate, have it reviewed by a Ministry leader for Patient follow up. Then scan
and email to
as soon as possible. Information that you provide can aid in determining further actions and
protecting the church against negligence.
1. Date & Time of Incident:
_________________________
Check a Location Box:
AU
CC
CL
EL
HCA
RM
NI
NS
Camp
Check a Ministry Box:
Worship Service
Adult
Student (Jr High/HS)
Childrens 4-5
K–3
Awana
Childrens
Preschool
Nursery
Incident Report Form Completed by:
Phone:
2. Patient Name
:
Age*
DOB
______________
Address:
City
State
Zip
Phone
_ *If patient is under 18 yrs, provide Parent/Guardian Name
______
Explanation of Incident Ask patient to explain what happened regarding the incident:
Check Patient Symptoms that Apply:
dizzy
light-headed
nausea
vomiting
abd pain
disoriented
passed out
sweating
chest pain
SOB
symptoms of stroke
bleeding from injury, location:
_____
Other
Allergies or Medications:
Last time ate: _ _________________________________
Medical History:
Diabetes
Asthma
Cardiac
Other:
________________________________
**By signing below, I state that the above information is accurate and the statement is a true account of this Incident.
Signature of Adult Patient or Child Guardian involved:
_________________________
3. Witness Information
Please provide witness names and numbers so we may follow up with them as necessary
Name
Phone:
_______________
Name
Phone:
_______________
Witness Observation Ask witness to explain what happened regarding the incident:
______________
______________
4.
Site Evaluation
Include any information or description of the site that may relate to the incident:
2015 Harvest Bible Chapel | Business Operations
Page 1 of 2

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 2