Incident Report Form

Incident Details

Incident Date:

Time of Incident:

Location of incident (be specific and detailed)

Who was involved?

Nature of injury or loss:

Context and circumstances of the incident:

Who else witnessed this incident? (include names and contact details)

Were any Authorities alerted? Police/Emergency Services/Medical.

If yes, who was contacted and what was the response?

Detail the follow up action to the incident:

I declare that this is a true and accurate report according to how I remember the incident occuring and the actions that followed. Please email any witness statements/photos/other supporting documentation to safechurch@kingsway.org.au.

First Name

Date of report submission:

Last Name