Safe Ministry | Incident Report Form • Emu Plains Anglican Church Online Community

Safe Ministry | Incident Report Form

Use this form to report an incident (including an injury, hazard, or near miss) for our Safe Ministry records. This form is applicable for children and adults.

Person making report

First Name *

Last Name *

Contact (phone/email)

Person affected

First Name *

Last Name *

Contact (phone/email)

Child or Adult? *

Child

Adult

Incident details

Date of incident *

Time (hh:mm am/pm) *

Where it occurred *

What occurred *

Description of injury (if applicable)

If an injury was sustained, how has that injury been triaged and treated?

First Aid

Doctor

Ambulance

Treatment given

Next steps

Parent advised *

Any additional action?

Witness (if applicable)

First Name

Last Name

Contact (phone/email)

Declaration

I acknowledge this form is complete and accurate to the best of my knowledge. *

Yes