Free Incident Report Template 37Free Incident Report Template 37Free Incident Report Template 37
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[Name of Church Here]
Incident/Accident Report Form
Must be filled out by Pastor
Form must be kept on file.
Church Name________________ erson completing Report__________________

Date:

PEOPLE
Person(s) Involved:
Age

Gender

Member

Staff

Visitor/Group

If member of Outside Group, is Waiver and Release on file?

Witness (es) to incident:
Name
Name
Name
INCIDENT
Type of Incident:

Behavioral

Age
Age
Age

Accident

Location:
What led up to the incident:

Describe the incident:

What actions were taken after the incident:

March 2011

Illness
Date:

Other
Time:

Yes No

INCIDENT REPORT pg 2

In case of injury, complete the following:

Identify type & bodily location of injury:

Was any injury a result of a violation of a rule, order, or law by the injured?

Yes

No

If yes, describe violation

List any objects or equipment involved in the injury:
Nature of first aid administered:
Person(s) administering first aid:
Did the injured leave the facility:

Yes

No

If yes, with whom?
Where