INCIDENT REPORT FORM: Accident/Personal Injury - Newton ...

Newton Highlands Congregational Church October 19, 2006Safe Church Policies and ProceduresINCIDENT REPORT FORM: ACCIDENT / PERSONAL INJURYName of ReporterRole/Function/Position of ReporterAddressTelephone (Home) (Work/Cell)Signature of ReporterType of Incident: Accident Personal Injury Other (Specify )DateTimeName of Person Involved in IncidentAddressTelephone (Home) (Work/Cell)Member Visitor Other (Specify )Minor ( Age Gender )If a Minor, Parent/Guardian Information, Date Reported to P/GName(s)AddressTelephone (Home) (Work/Cell)Member Visitor Other (Specify )A14

Newton Highlands Congregational Church October 19, 2006Safe Church Policies and ProceduresC. Describe the nature of the accident/ injury/otherLocation of accident/injury/otherDescribe the circumstances under which you became aware of the incident. Include thenames of name(s) of any witnesses.Immediate Action Taken (if any)A15

Newton Highlands Congregational Church October 19, 2006Safe Church Policies and ProceduresAdditional information that may be helpful in establishing the cause of the incident.Reported to DateD. Action(s) takenAdditional Comments (if any)Name DateRole/Function/PositionSignatureReported to DateA16