"Incident/Accident Report Form - Royal Redeemer Lutheran Church"

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Download "Incident/Accident Report Form - Royal Redeemer Lutheran Church"

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I
/A
R
F
NCIDENT
CCIDENT
EPORT
ORM
In the event of an incident or accident, please contact staff immediately.
Additionally, please complete and submit this form to the church office.
Date of incident: _______________ Time: ________ AM/PM
Location of occurrence:
Name of injured person:
Address:
Phone Number(s):
Date of birth: ________________
Male ______ Female _______
Name of reporter/church representative:
_______
______
Phone Number(s):
Incident/Accident Details:
Who was injured person?
Staff
Volunteer
Participant
(circle one)
Type of injury:
Details of incident:
Details of response:
Injury requires physician/hospital visit?
Yes ___
No _____
Name of physician/hospital:
Address:
Physician/hospital phone number:
______________________________________________________________________________
Signature of injured party
Date
Signature of reporter/church representative
Date
Return this form to Church Staff within 24 hours of incident.
Royal Redeemer Lutheran Church
7127 Dutchland Parkway
Liberty Township, OH 45044
I
/A
R
F
NCIDENT
CCIDENT
EPORT
ORM
In the event of an incident or accident, please contact staff immediately.
Additionally, please complete and submit this form to the church office.
Date of incident: _______________ Time: ________ AM/PM
Location of occurrence:
Name of injured person:
Address:
Phone Number(s):
Date of birth: ________________
Male ______ Female _______
Name of reporter/church representative:
_______
______
Phone Number(s):
Incident/Accident Details:
Who was injured person?
Staff
Volunteer
Participant
(circle one)
Type of injury:
Details of incident:
Details of response:
Injury requires physician/hospital visit?
Yes ___
No _____
Name of physician/hospital:
Address:
Physician/hospital phone number:
______________________________________________________________________________
Signature of injured party
Date
Signature of reporter/church representative
Date
Return this form to Church Staff within 24 hours of incident.
Royal Redeemer Lutheran Church
7127 Dutchland Parkway
Liberty Township, OH 45044