Accident, Incident and "Near miss" Report Form
All accidents and incidents, however slight, must be reported to enable the Church to comply with Health, Safety and Environmental regulations.
Use this form to report: a) any injury sustained; b) any health and safety incident without injuries; c) any illness arising from work; d) any environmental incidents and e) any Church security incident involving threatening behaviour or violence.
Full Name of person filling in form
Contact details of person filling out the form
Details of Injured Person (if applicable)
Name, Address, DOB, Status (eg. Employee, Contractor, Child, Visitor)
Details of Accident/Incident/Illness/Near Miss
Location of occurrence, Date, Time, Emergency services called?
Briefly describe the circumstances:
Accident/Incident Type (please choose one)
Struck by moving/flying/falling object
Struck a fixed/stationary object
Fall from height
Slip/trip/fall at same level
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