Incident and Injury Report Form • Immanuel Woden Valley Lutheran Church

Nature of Event

When and where did this event occur?

Time of Event (specify AM/PM) *

Date *

Location Name *

Exact Place *

Name of the activity *

Team Leader

Surname *

Given Names *

People involved in the event

(including witnesses - attach signed and dated reports of witnesses if applicable)

People involved *

Summary of the event

(include a summary of the hazard/near miss/sensitive incident that might be relevant to this event)

Summary *

Person 1

(Details of injured person if applicable - remember to fill in injury details)

Surname *

Given Names *

Street Address *

Suburb *

Postcode *

Date of Birth *

Phone

Mobile *

Person 2

Surname

Given Names

Street Address

Suburb

Postcode

Date of Birth

Phone

Mobile

Names and details of additional people involved *

Injury Details

(to be completed only if the event involved injury)

The injured person was a

Initial Severity Assessment

Part of body injured (Doctor appointment for body parts marked *)

Other (please specify)

Nature of Injury

Other (please specify)

Cause of most Severe Injury

Other (please specify)

Immediate Treatment

Remember, note the times and be as detailed as possible in the action that was taken to care for the casualty. (Give details. Include additional notes if required.)

Immediate Treatment Actions & Notes

Doctor

Surname

Given Names

Street Address

Suburb

Phone

Postcode