FBC INJURY/INCIDENT REPORT

The following form must be filled out should an injury occur during any church-sponsored function. It is important to maintain records of any incidents/injuries incurred during a church-sponsored function in case of insurance or liability questions.

Your name *

Email address *

Date of incident *

Time of incident *

Did this incident/injury happen within a specific Frontline Ministry?

Who? *

Are you a:

Name *

What is the name of the person involved in the incident or injury?

Location *

Please give a detailed location of where the incident/injury happened and where you were.

Details *

Please give a detailed description of the incident/injury including how, who, why.

Where you a direct witness of the incident/injury? *

Witnesses

If you were not the sole witness of the incident/injury please include the names of any other witnesses.

Action Taken/Medical Treatment Provided *

Please include any information on action taken or treatment provided concerning this incident/injury.