Incident / Hazard Report Form • Berwick Church of Christ Inc.

If you were involved in the incident or a witness to the incident, please also add your details to the List of People Involved below.

First Name *

Last Name *

Mobile Number *

Email Address *

Please provide the name of the Leader / Pastor you reported this incident/hazard to: *

Incident/Hazard Date *

Incident/Hazard Time (e.g. 9:00am) *

Incident/Hazard Details (select all relevant) *

Person(s) were injured or suffered illness

Ambulance was called

Police were called

Hazard Identified

Had the potential to result in injury or illness (near miss)

Please provide the location where incident occurred or where hazard was identified. *

Describe how the incident occurred or hazard was identified. (List sequence of events preceding the incident/hazard.) *

Was any equipment or facilities damages? *

Yes

If the equipment was damaged, please provide details of the equipment/facilites damaged.

Please complete the following for each person involved in the incident, including witnesses.

If more people were involved please add the same details as for Person 1 and Person 2 here, as many times as necessary.

I declare that the information contained in this form is true and correct to the best of my knowledge.

Electronic Signature *

I agree that by checking this box, I am electronically signing this application and agree to the above declaration.

Add the date this application was completed. *