MBC Incident/ Accident Report
Details of Person(s) involved in incident:
First Name
*
Last Name
*
Gender
Male
Female
Date of Birth
Details Of Incident:
Date of Incident:
*
Location of Incident:
*
Details of Incident (please write details of injury and did this injury occur):
*
Where Was Injury Sustained?
*
Any damage to church property or equipment due to this incident? (What was damaged, level of damage).
Which Ministry Area Did The Incident Occur In?
Friday Youth
Sunday Kids
Sunday Youth
Morning Church
Evening Church
Other
What Ministry Did The Incident Occur In?
Did this happen to somone under 18?
Yes
No
Were there witnesses to the incident/ accident (please list names, numbers and statements)
First Aid/ Medical Attention Given:
What Forms of First Aid were Administered?
*
Who Administered First Aid?
*
Was There Further Action Needed?
Incident Documented By:
Were Parents Made Aware of Incident?
Yes
No
When were they made aware?
When will parents be made aware?
Incident Reported By:
*
Date of Reporting:
*
Reflective Actions (Please Fill Out Appropriate):
Was this incident/ accident related to any planned activity?
Yes
No
What were the instructions given for this activity?
What were the Weather conditions at the time of incident?
Was equipment used appropriately checked and found suitable for activity?
What are the corrective actions in relation to this incident?
*
Office Only
Has this incident been escalated and to whom?
Is the incident a 'Serious Event' notifiable to WorkSafe?
Other Details
Submit