Church Incident Report Form
Name of the Person Completing This Form
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Relationship to Church
Member
Visitor
Employee
Student
Other
Incident Details
Â
Reason for Report
Incident Date & Time
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Incident Location
People Involved
Property Damaged
Please describe what happened briefly
Was ambulance called?
Yes
No
Not sure
Please give details
What action did you take or was taken at the time?
Has the cause of the incident been removed?
Yes
No
N/A
Not sure
Are there other follow-up steps you believe should be taken?
Yes
No
N/A
Not sure
Please list the steps should be taken:
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: