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 *

Date *