[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__________________
If member of Outside Group, is Waiver and Release on file?
Witness (es) to incident:
Type of Incident:
What led up to the incident:
Describe the incident:
What actions were taken after the incident:
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?
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:
If yes, with whom?