Faith Fellowship Church - WA

INCIDENT REPORT

Use this form to report an injury or an incident that took place on church grounds or in the building. If the person injured requires medical attention please call 911.

Name of Person Completing Form

Last Name

Email of Person Completing Form

Phone Number of Person Completing Form

Date of Injury/Incident

Injured Person(s)

Where did the injury occur:

Description, be as specific as possible, of injury and how it occurred:

Witnesses to injury:

Action Taken or Medical Treatment Provided:

Was one of the AED machines used?

YES

NO

Was 911 called during the incident?

YES

NO

Signature of Person Completing Form

INCIDENT REPORT

INCIDENT REPORT

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