Incident / Injury Report

INCIDENT / INJURY REPORT FORM

In the event of an incident / injury, as a volunteer or leader you are expected to:
- respond to incidents appropriately and promptly and take action.
- use appropriate report forms: Injuries or accidents requiring secondary medical attention, e.g. visit to a doctor or medical centre, are to be written up on an incident report.
- incidents of a serious nature need to be reported to the local church insurer.
- report all incidents to parents and/or care-givers of children or young people, and in instances where the impact has been felt by a wider group, report, with the permission of those involved in the incident, to the wider concerned group.

INCIDENT / INJURY REPORT FORM

* Indicates required field

1. INCIDENT / INJURY TYPE *

2. NAME OF PERSON INVOLVED / INJURED *

DATE OF BIRTH (dd/mm/yyyy) *

GENDER *

OCCUPATION / COMPANY (If contracting work) *

3. DATE OF INCIDENT / INJURY (dd/mm/yyyy) *

TIME OF INCIDENT / INJURY *

4. INCIDENT / INJURY LOCATION DETAILS (Where on the premises (or elsewhere) did the incident / injury occur?) *

Describe how the incident / injury occured, any other persons involved, and what was happening at the time of the incident / injury. *

5. INCIDENT / INJURY DAMAGE (Describe the type of injury (if applicable - eg strain to lower back) *

Was there any damage to any property or to anyone's belongings? *

PROPRTY DAMAGE: (specify the damage if applicable) *

6. TREATMENT *

AMBULANCE / HOSPITAL *

POLICE NOTIFIED *

7. WITNESSES (Did anyone directly witness the incident / injury?) *

Name and phone number of witness (if applicable) *

8. DATE OF REPORT (today) (dd/mm/yyyy) *

NAME OF PERSON LODGING REPORT (you) *

Thankyou for taking the time to complete this report. It will be forwarded to ALC admin once submitted.

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