Safe Church - MBC INCIDENT FORM • Mayfield Baptist Church

MBC Incident Form - Accident / Injury / Near Miss / Damage

It is important that this form be filled in on-line rather than on printed paper. It has many areas to fill in based on some answers given.

Please use multiple forms to report, if multiple people are involved.

Any requirements for attachments should be emailed to safechurch with a subject heading of Name of Reporter and Date.

Please follow up witnesses to ensure everything required is submitted.

INCIDENT REPORT documented by:

First Name *

Email Address *

DATE Reported *

Last Name *

Mobile Number *

Role of Person reporting Incident

INCIDENT Details

Category of Incident *

First Name of Person Affected *

Address of Person involved *

Best Phone Contact Number

DATE of Incident *

Surname of Person affected *

Date of Birth or Age (even if approx)

Relationship of Person Concerned to Mayfield Baptist Church (MBC)

Location/Address of Incident *

Specific area where Incident occurred *

In your opinion is this a Worksafe matter? *

Time of Incident *

What was affected - List all that apply *

Other - Please specify *

Description of Incident. Please provide drawings or photos as relevant and with permissions obtained, and attach in an email to safechurch@mayfieldbaptist.com *

Which body parts were affected by the incident - If required, please draw onto an outline of a body, (see link below) to illustrate, and email drawing to safechurch@mayfieldbaptist.com *

Human Body Outline

Human Body Outline

Witnesses

Please list all people who were direct witness to incident. Request them to submit their own account of the incident by email to safechurch@mayfieldbaptist.com.

If a serious incident has occurred please provide an electronic form (via website link) and request them to document same incident as a witness

Full Name of Witness/es *

Tip: If no witnesses, please state 'no witnesses'

Contact Details of Witness/es *

Tip: If no witnesses, please state 'No Witness'

ACTIVITY

What was the Ministry in progress at the time? *

Tip: write N/a if no ministry happening

What instructions or training were given prior to incident? *

Was PPE available? *

What was the activity taking place at the time? *

Was equipment checked and found suitable? *

Was PPE checked and found suitable? *

Context for Incident

What was the initial/main/central cause for the Incident? *

Weather conditions at time of incident

Other factors pertinent to Incident *

What corrective action was initiated immediately? *

What corrective action was initiated / recommended ongoing? *

First Aid

Who administered First Aid? - Provide name/s and contact details *

Was further medical attention required or recommended *

Describe First aid given in sequence *

What was the result of the First Aid given? *

Other - list details *

Additional / Escalated Medical attention

Provide Details of further Medical Attention if known *

Name of Hospital if provided by Parent or Emergency Services (or write 'not known' or 'N/A') *

Property/Equipment Damage

Who have you ALREADY reported the damage to? *

Do you believe the site is safe as well as secure? *

Finalising Report

Please provide any further details for follow up or for information *

Form Completed - Please go to Submit *