Incident Report - Grace Anglican Church

Incident Report

Incident Details *

Date Time Type of Incident Location of the Incident

Details of the Affected Person

Full name * Date of birth * Address Phone Email

Reporting the incident *

Name of person who reported the incident Ministry position of person who reported the incident Name of Ministry leader the incident was reported to Name of Ministry leader’s position Date incident reported Time incident reported Name of parent/guardian the incident was reported to Date parent/guardian was advised

Treatment information

First Aid Doctor Ambulance Other:

Details of the alleged injury *

Description of the incident *

Action taken *

Witness information

Name of the person submitting the report *

Name of the person submittiing this form Position of the person submitting this form Date of report submission

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