"Church Incident Report Form - Presbyterian Church of Victoria"

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Download "Church Incident Report Form - Presbyterian Church of Victoria"

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Presbyterian Church of Victoria Incident Report
Name of Church:__________________________________________________________________
Address:
_____________________________________________________________________
Contact Person:___________________________________________________________________
Telephone: _____________________________ email: ___________________________________
Details of injured Person
Name:__________________________________________________________________________
Address:
_____________________________________________________________________
Congregation Member Yes/No
Visitor Yes/No
Male/Female
Details of Incident
Date of Incident:________________
Time of Incident: _____________
Type of Activity _____________________________
Accident Description:_______________
Brief Details: ____________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Accident Site: ____________________________________________________________________
Names of Witnesses: ______________________________________________________________
Details of Injury
Nature of Injury: __________________________ Location of Injury: _______________________
Severity of Injury: ________________________________________________________________
Treated by Dr: __________________________
Hospital: ______________________________
Has a claim been made
Yes/No
When? ______________________________________________________________
Details of claim: __________________________________________________________________
__________________________________________________________________
Signed: ________________________________________
Dated: _____________________
Presbyterian Church of Victoria Incident Report
Name of Church:__________________________________________________________________
Address:
_____________________________________________________________________
Contact Person:___________________________________________________________________
Telephone: _____________________________ email: ___________________________________
Details of injured Person
Name:__________________________________________________________________________
Address:
_____________________________________________________________________
Congregation Member Yes/No
Visitor Yes/No
Male/Female
Details of Incident
Date of Incident:________________
Time of Incident: _____________
Type of Activity _____________________________
Accident Description:_______________
Brief Details: ____________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Accident Site: ____________________________________________________________________
Names of Witnesses: ______________________________________________________________
Details of Injury
Nature of Injury: __________________________ Location of Injury: _______________________
Severity of Injury: ________________________________________________________________
Treated by Dr: __________________________
Hospital: ______________________________
Has a claim been made
Yes/No
When? ______________________________________________________________
Details of claim: __________________________________________________________________
__________________________________________________________________
Signed: ________________________________________
Dated: _____________________