Incident Report

This form is to be completed any time an emergency event occurs. Please fill out in as much detail as possible.

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Date / Time of Incident *

Date

Time

Report Completed By: *

Type of Event: *

(Worship, fitness class, etc.)

Location *

Briefly describe the incident: *

Were there any injuries? If so, list names of those injured and describe the injuries: *

for any in

Describe any actions taken, including contacting emergency personnel:

List any witnesses or those involved in the incident:

Describe any actions taken later to follow up on the incident:

Suggestions for changes in ongoing operations in light of this incident:

Submit