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

This is a required question

Contact details of person filling out the form

Mobile/email

This is a required question

Details of Injured Person (if applicable)

Name, Address, DOB, Status (eg. Employee, Contractor, Child, Visitor)

This is a required question

Details of Accident/Incident/Illness/Near Miss

Location of occurrence, Date, Time, Emergency services called?

This is a required question

Briefly describe the circumstances:

This is a required question

Accident/Incident Type (please choose one)

This is a required question