Incident and Injury Report

Submission details

Name of person submitting this form

Phone number

Email

Parish

Other - please specify

Date and Time of Incident

Location of IncidentInclude details such as name of church centre and location on the premises i.e. in the vestry

Describe the IncidentInclude details of where, who and what was happening at the time

Did anyone sustain an injury during the incident?

YesNo

Please provide contact details for each injured person, their parent or guardian if under 18 years of age, and each first aider.

Name

Phone Number

Email

Involvement

Under 18yrs?

Describe injury/injuries sustainedi.e. right forearm of [name] - bruised and small scratch

Provide details of first aid or assistance provided

If a hazard was involved, what steps were taken to reduce the hazard and prevent reoccurance?

Name

Phone Number

Email Address

Were there any other witnesses to the incident

YesNo

Name

Phone Number

Email Address

Who else has been notified?

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