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Incident Report
Use this form to report accidents, injuries, medical situations, criminal activities, traffic incidents or student behavior incidents. If possible, a report should be completed within 48 hours of the event.
Your name
*
Last name
Email address
*
Phone number
Phone type
Mobile
Home
Work
Other
PERSONAL INFORMATION
The following information is about the person involved in the incident.
Relationship to Church
*
Member
Visitor
Other
Name of Person Involved
*
Gender
*
Select…
Male
Female
Age of Person Involved
*
Were there other persons involved?
*
YES
NO
THE INCIDENT
Following questions pertain to the incident.
Date of Incident
*
Date
Time of Incident
*
Location of Incident
*
Campus Grounds
Santurary
Fellowship Hall
Classroom
Other
PROPERTY DAMAGE
List or describe any property that was damaged in the incident.
Describe in detail what happened
*
Was any property damaged during the incident?
*
YES
NO
INJURIES
Describe all injures if any that occurred.
Was anyone injured?
*
YES
NO
Was an ambulance called?
*
YES
NO
Were the police called?
*
YES
NO
What action did you take or was taken at the time of incident?
*
Has the cause of the incident been resolved?
*
YES
NO
Are their other follow-up steps you believe should be taken?
*
YES
NO
List any additional steps that should be taken:
WITNESSES
Were there witnesses to the incident?
*
YES
NO
SIGNATURE
Todays Date
*
Date
Signature: PRINT NAME BELOW to sign form electronically.
*
Submit
A copy of your responses will be sent to your email address.
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