Incident Reporting FormFill this in on your phone. Tap the boxes and type in the blanks. What you enter is kept on this phone while you work. When you are done, send it to the safety team, or print it.Appendix 10 – Incident Reporting Form [ Church name ] church Incident reporting form Instructions: This form must be filled out for ALL incidents, including near misses, injuries, illnesses, and property damage. Complete it as soon as possible after the incident and submit it to the Health and Safety Champion. A more comprehensive online form can be found from the QR code below: Figure -Incident Report Incident details Field Information Date of Incident: Time of Incident: Location of Incident: Weather Conditions (if relevant): Person(S) involved Field Person 1 Person 2 Name: Age: Address: Phone Number: Email: Status: StaffVolunteerMemberVisitorContractor StaffVolunteerMemberVisitorContractor Type of incident Injury - Describe Illness - Describe Near Miss - Describe Property Damage - Describe Other - Describe Injury details (if applicable) Part of Body Injured: Type of Injury: Cut/LacerationBruiseSprain/StrainFractureBurnOther Medical Treatment Required: No treatment requiredFirst aid onlyMedical centre/GPHospital emergency departmentHospital admissionOther Incident description What happened? (Provide a detailed description of the incident) What was the person doing at the time? What equipment/tools were being used? What factors contributed to the incident? Immediate action taken First Aid Provided: YesNo By Whom: Emergency Services Called: YesNo Which Service: AmbulancePoliceFire Service Other Action Taken: Witnesses Name Contact Details 1. 2. 3. Reporting details Reported By: Position: Date Reported: Signature: For office use only Received By: Date: Investigation Required: YesNo Investigator Assigned: WorkSafe Notification Required: YesNoUncertain If Yes, Notified: YesNo Date Follow-up Actions Required: Completed By: Date: Finished?Website Your name *Send to the safety teamPrint or save as PDF Clear everything