Incident Form

This Incident Form is where incidents that result in an injury will be documented. Anytime an injury is reported to, or a volunteer witnesses the incident, it shall be documented on an incident form; no matter how severe or minor.

This form must be filled out by any Ministry leader who is made aware of or witnessed the incident. This form must be filed within 24 hours of the injury being reported to them.

When the form is submitted, a copy will automatically be sent to the Lead Pastor, Executive Pastor, Chief Financial Officer (CFO), and the Safety and Security Director(s).

Your name *

Email address *

HCC Incident Form] Incident Information:

Date of Incident *

Time of Incident *

At which Service or Event did the incident take place? *

Specifically, where did the incident take place?

(i.e. Sanctuary hallway, Ministry Center lobby, offsite - skating rink, etc.)

Detailed Description of Injury Incident:

Location of injury on the individual *

Please provide a detailed description of what transpired during the incident: *

Injured Individual's Information:

Full Name *

Date of Birth

Address

Phone Number *

Parent/Guardian Full Name

(Provide if injured individual is under the age of 18. If they are over the age of 18, please type N/A)

Parent/Guardian Phone Number

(Provide if injured individual is under the age of 18. If they are over the age of 18, please type N/A)

Did you notify a family member, friend or other person related to the individual other than the Parent/Guardian? If so, please list their Full Name and Phone Number below.

(If not, please type N/A)

Injury Incident Witness Information:

Witness Full Name *

Witness Phone Number *

Outside Agency Information:

If Ambulance/EMS responded, provide the Medic #:

If Police responded, provide the Case or Incident #:

If Fire responded, provide the Case or Incident #:

If Other agencies responded, provide contact information:

Follow-Up:

Is follow-up needed?

If yes or unsure, who should follow-up?

Signature:

Please write your full name below as a digital signature confirming that the details listed above are correct to your best knowledge:

A copy of your responses will be sent to your email address.