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.
* Required
Full Name of person filling in form
*
Your answer
Contact details of person filling out the form
*
Mobile/email
Your answer
Details of Injured Person (if applicable)
Name, Address, DOB, Status (eg. Employee, Contractor, Child, Visitor)
Your answer
Details of Accident/Incident/Illness/Near Miss
Location of occurrence, Date, Time, Emergency services called?
*
Your answer
Briefly describe the circumstances:
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Your answer
Accident/Incident Type (please choose one)
*
Choose
Near Miss
Struck by moving/flying/falling object
Struck a fixed/stationary object
Fall from height
Moving/handling
Assault/violence
Electrical
Trapped
Hazardous Substance
Machinery/equipment
Sharp object
Slip/trip/fall at same level
Sports
Theft
Other
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