Radius Church Incident Report

RADIUS CHURCH INCIDENT REPORT FORM

This form submits directly to the Office of the Lead Pastor.
Instructions:
1. This report should be completed withing 24 hours of the incident. (Injuries should be reported immediately a ministry leader or work supervisor.)
2. Complete one incident report per individual involved.
3. All questions should be answered. (unless the information is not known)
Your Name*

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Information about Person Involved in Incident
Name*

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Incident Information
Date of Incident*

MonthDayYear
Date
Time of Incident

Hour Minutes

AM/PM Option
Location of Incident*
ie. Rear Foyer of Worship Center
Nature Of Incident*
Injury or Health Issue
Is the injured person a minor?
Was a Parent Notified?
Name of Parent / Legal Guardian Notified

First NameLast Name
Please enter the cause of the injury or describe the health issue incident.*
ie. Tripped over displaced concrete.
Please enter a detail description of injury or health incident.*
ie. Right ankle appears to be sprained with swelling. Right cheekbone is red.
Did this person get injured while on the job?

Yes, the injured individual is a vendor for Radius ChurchYes, the injured individual is on staff at Radius ChurchNo
What help was recieved?*

First AidSent HomeSent to DoctorSent to HospitalOther
Name of person who provided first aid.*

First NameLast Name
What first aid was given.*
ie. Ice applied to ankle and cheekbone. Support wrap applied to ankle.
If sent to a doctor or hospital, please provide name of facility.
Was anything done to prevent recurrence?
ie. Orange hazard cone placed at displaced concrete.
Theft / Vandalism
Was the damage to and/or theft of Humble First's property?*
Please describe the damage to and/or theft of Humble First's property.
Was there damage to and/or theft of another individual's property?*
Please describe the damage to and/or theft the other individual's property.
Was law enforcement notified?
Please enter the police report number:
Name of Responding Officer
Officer's Department Phone Number
Please enter a valid phone number.
Abuse and/or Neglect Reporting
Before completing this form, read Humble First's "Child, Disabled Adult, or Person age 65 Years or Older Abuse, Neglect, or Exploitation Reporting Guidelines and Procedures"

You will be contacted by a senior church staff member. Please do not discuss this matter with anyone else (except as required by law).
Types of Abuse and/or Neglect Disclosed or Suspected*

PhysicalSexualEmotionalNeglectExploitationOther
What was disclosed? / Why is it suspected?*
Suspicious or Unusual Activity
This section should be completed if there is any activity that you feel is suspicious or unusual activity that takes place on church property or might affect church participants at an off-site church event. (Suspicious or unusual activity examples: unknown person walking around after hours checking for unlocked doors, two individuals alone in a dark place, person(s) loitering in or around bathrooms.)
Describe suspicious or unusual activity.
If known, please provide names or descriptions of individuals involved.
Should be Empty:

RADIUS CHURCH INCIDENT REPORT FORM

Information about Person Involved in Incident

Incident Information

Injury or Health Issue

Theft / Vandalism

Abuse and/or Neglect Reporting

Suspicious or Unusual Activity