Incident Report Form - Centenary Evangelical Church

Date of Report *

Date of Incident *

Location of Incident *

Options below are the usual location of activities for the respective groups.

MPC - Church Service Area

D Block/Old Hall - Junior Kid's Church Area

OSHC - Primary Kid's Church Area

Jamboree Heights State School - Other Area

Other

Names of Persons Involved in Incident *

Individual/s affected, perpetrator, victim.

Name of ALL Witnesses *

Incident Category *

Accidental Injury

Aggressive Behaviour by Child

Volunteer Misconduct

Uncontrollable and Prolonged Misbehaviour by Child

Other

Description of Incident *

Please write a statement of the facts and details of the incident, including descriptions of all injuries, and the seriousness of these.

Immediate Action Taken *

Reason Given If No Action Was Taken

Submission