Incident Report Form - Westwood Baptist Church

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Westwood Baptist Church
Incident Report Form
This form shall be used by staff and/or members that witness or become aware of an
incident causing injury and/or damage to property.
This report shall be given to a staff member or turned into the church office as soon
as possible.
Person Completing this Report:
____________________________________
Reason for report: ________________________________________________
Date of incident: ______________________________ Time: ____________
Place of incident: _________________________________________________
Name(s) Injured: _______________________________Age: _____________
Address:__________________________________________________________
__________________________________________________________________
__________________________________________________________________
__
(Add others if necessary)
Property Damaged:
__________________________________________________________________
_
__________________________________________________________________
_
Briefly describe what happened:
__________________________________________________________________
_
__________________________________________________________________
_
__________________________________________________________________
_
__________________________________________________________________
_
Incident Report Form
Westwood Baptist Church
Incident Report Form
This form shall be used by staff and/or members that witness or become aware of an
incident causing injury and/or damage to property.
This report shall be given to a staff member or turned into the church office as soon
as possible.
Person Completing this Report:
____________________________________
Reason for report: ________________________________________________
Date of incident: ______________________________ Time: ____________
Place of incident: _________________________________________________
Name(s) Injured: _______________________________Age: _____________
Address:__________________________________________________________
__________________________________________________________________
__________________________________________________________________
__
(Add others if necessary)
Property Damaged:
__________________________________________________________________
_
__________________________________________________________________
_
Briefly describe what happened:
__________________________________________________________________
_
__________________________________________________________________
_
__________________________________________________________________
_
__________________________________________________________________
_
Incident Report Form
Was Ambulance Called?
Yes
No.
Comments:________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
____
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What action did you take or was taken at the time?
__________________________________________________________________
_
__________________________________________________________________
_
__________________________________________________________________
_
__________________________________________________________________
_
Were there any witnesses?
Yes
No
List others who witnessed the incident or responses:
Name:_____________________________________Phone:_________________
Name:_____________________________________Phone:_________________
Name:_____________________________________Phone:_________________
Name:_____________________________________Phone:_________________
Has the cause of the incident been removed?
Yes
No
N/A
Explain:__________________________________________________________
_
__________________________________________________________________
_
__________________________________________________________________
_
__________________________________________________________________
_
Are there other follow-up steps you believe should be taken?
Incident Report Form
__________________________________________________________________
_
__________________________________________________________________
_
__________________________________________________________________
_
__________________________________________________________________
_
Incident Report Completed By:
_____________________________________________Date:________________
_
(Signature)
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Incident Report Form
For Staff Use Only
Was the insurance company informed:
Yes
No Date: ________
Date contact made with injured parties: ___________________________
Name of staff person following up: _________________________________
Briefly describe what injured party alleged happened:
__________________________________________________________________
_
__________________________________________________________________
_
__________________________________________________________________
_
__________________________________________________________________
_
Is additional investigation needed?
Yes
No
Explain: _________________________________________________________
__________________________________________________________________
_
__________________________________________________________________
_
__________________________________________________________________
_
Was the incident reported to local authorities?
Yes
No
By Whom:_______________________________________________________
Reported to:______________________ Time:_______Date:_____________
Investigating Police
Officer:___________________________________________________________
Star/Badge #:__________________
Signed: (Staff Member):
_______________________________________________Date:______________
_
Incident Report Form
This report should be kept on file in the church office for a Minimum of three years
from date of incident.
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Incident Report Form

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