Incident Report Form This form is used to report any accident/incident that occurs as a part of a church ministry activity (eg. Boing Night) or simply occurs on the church property. Step 1 of 6 16% Details of Person Reporting the IncidentYour Name*Your Email*To receive a copy of this email Ministry*Incident on the Church PropertyPlaytime PlusKids ChurchKids QuestSchool Scripture - PrimaryHigh School SREQuenchToongabbie Christian SchoolYoung AdultsMen Being MenWisdom for WomenSenior FriendsHospitality - Morning TeaHospitality - SupperCafe180 Life CareLife GroupsWelcome and IntegrationChurch CarePrayerLibraryOverseas MissionCricketCreative ServicesMusicDecoratingMinistry Oversight Reporting:*Roger - Services / LeadershipMark - Welcome / DiscipleshipLucas - ChildrenFiona - Youth / Young AdultsAshley - Creative ServicesAgnes - Office / AdminEvent unrelated to a MinistryIf you are unsure about who is your staff ministry mentor please return to Ps Roger who will assist. Details of Person(s) injuredName(s)*AddressGender*Telephone No*Date of Birth*Student/Teacher/Contractor/Staff Member/Private Camper/____________ (Fill in blank if other) Details of the IncidentIncident Report documented by*Date Reported*Time of Incident*Date of Incident*Location of Incident*Area/Activity that incident occured*Description of Incident* Details of the InjuryNature of the Injury (eg. burn, cut, sprain)*Cause of the Injury (eg. fall, grabbed by person)*Location on Body (eg. back, left, forearm)*Agency (eg. lounge chair, another person, hot water)*Witnesses (Name/Address/Telephone no. of witness - Written Statements to be attached separately)*Treatment Administered* First Aid given - Yes First Aid given - No Treated by Doctor Hospitalised First Aider NameDoctor's NameTreatment*Was medical attention sought as a result of the incident? (provide details if known)*Other factors to the incident (eg. Weather) ?* Work, Health & Safety / Risk AssessmentEquipment checked and found suitable? (Broken or damaged equipment retained)*Personal Protective Equipment checked and found suitable?*What instruction and training was given in relation to the activity?*Likelihood of recurrence:*Level of risk:*What was the Root Cause of the incident?*Corrective actions instigated to prevent reoccurence (both immediate and ongoing)?*Was there any damage to equipment and or buildings/property due to the incident? Have Property Deacons been informed to ensure site is made safe and repairs conducted if applicable?* NotificationsHas the issue been escalated to the authorities (where required) ?*TB Church Leaders Notified?* Yes No Who:DateHow Notified? (Phone/Email)Baptist Insurance Notified :* Yes No Who:DateIs the incident a 'Serious Event' notifiable to WorkSafe?*OTHER DETAILS
