Incident • C3 Church Auckland

Incident/Accident Report

(including near misses and incidents of unsafe acts or conditions)

First Name

Last Name

Full Name

Location of incident/accident

If you selected 'Other', please clarify

Time of incident/accident

Date of incident/accident

Treatment of injury

If you selected 'Other', please clarify

How did the accident/serious harm happen?

Tip: (Please give as much details as possible)

Was a staff member/location Pastor notified?

Form completed by (Full Name):

Date person completed form