English » The Methodist Church of New Zealand

Incident Report Form

*Parish name?

*Church name?

*Your name

*Your telephone number

*How serious was the incident you had or were witness to:

Was it a...

Near miss [nothing happened but it might/sticking plaster or less to fix]

Minor Incident [more than a sticking plaster/ people had to help]

Major Incident [major first aid/doctor follow up/ambulance/hospital/stop work/asbestos/contamination]

*Date of Incident

*Time of Incident

*Address where incident occurred:

*Location at address where incident occurred (be specific so others can identify the spot):

*What happened?

*What treatment was given to anyone, if any?

*Has any action been taken to stop it happening again? (who did what, and when):

*Is the issue fully fixed?

Yes

If necessary, do you have further suggestions to fix the problem?

*Your email (a copy of this report will be emailed to you):

Additional email to copy notification to? (Optional)

Add files or photos to report (16Mb max.)