Incident Report (2023 onwards)

Incident Details

Depending of the severity of the incident, you will be directed to answer just a few questions or complete a full incident report. Please contact your team leader or safeministry@tac.church if you are unsure.

First name of affected person *

Surname of affected person *

Date of incident *

Approximate time of incident *

Type of incident *

Minor first aid incident (band aid, ice pack, etc.) or behavioural incident (no harm caused to child, other children or leaders)

Incident involving injury or behavioural incident (harm caused to child, other children or leaders)

Minor Incident Report

Comments about incident

Please list any first aid kit items used (if applicable)

Are there any first aid items that we are low on or that need to be ordered?

Parents contacted at the time of the incident?

Yes

Parents to be notified at time of pick up?

Yes

Further follow-up needed?

Yes

Notes on follow-up

Full Incident Report

Please complete all fields, if possible.

Affected person's address

Affected person's email address

Affected person's contact number

Affected person's date of birth

Reported by

Position

Reported to (staff member or team leader)

Position

Date reported

Approximate time reported

Reported to parent/guardian (name)

By whom

Date reported to parents

Treatment Information

First aid

Yes

Please list any first aid kit items used (if applicable) so they can be replenished.

Doctor

Yes

Ambulance

Yes

Incident and Witnesses

Description of incident, including details of alleged injuries

Full name of Witness 1

Contact details for Witness 1

Full name of Witness 2

Contact details for Witness 2

Full name of Witness 3

Contact details for Witness 3

Action taken

Person Completing Form

Name of person completing report *

Position of person completing the report *

Signature *

I confirm that all details provided in this report are accurate, to the best of my knowledge.

Date *

Do not give a copy of this report to the affected person.

This completed report is to be kept with the Safe Ministry records indefinitely.

If you have used the last item of something in the first aid kit, please notify Sally asap (sally@tac.church).