Incident / Injury Report

MOBC - Incident / Injury Report Form

This form is to be completed whenever an incident occurs on Church property or on Church arranged outings/events.

If the incident involves a child (Under 18) an adult witness is required to complete this form.

Date of Incident *

Time of Incident *

First Name

Last Name

Gender

Date of Birth

Home Address

Mobile Number

Email Address

Is the person involved under 18? *

Yes

If Yes, has a parent or carer been informed?

Yes

Description of Incident *

What area of the body was injured?

Was first aid given? If so, by whom?

Where on the property did the incident happen?

Tip: ie, Rivergum Hall, courtyard, kitchen

Were you attending an event or activity? If so, which one?

Ministry Area *

Tip: ie, Youth group, Holiday Bible Club, Kids Church

Was there any damage to equipment and or buildings/property due to the incident?

Did any one Witness the incident? If so who?

Additional comments

Name of the Person submitting report *