Incident/Accident/Hazard Report

An incident that requires reporting is an event which involves any of the following:

accident
moderate or serious injuries, or damage to property/equipment
'near misses’ which may have caused any of the above
serious or ongoing breach of the accepted Code of Conduct
criminal activity of leaders, congregational members or visitors
behaviour or circumstances which threaten the safety of staff, volunteers or visitors
complaints or unresolved disputes
allegations of misconduct or abuse by anyone

First Name *

Last Name *

Email Address *

Location of event *

Date of Event *

Time of event *

Type of Incident *

Description of the incident *

Other people affected

Tip: Names and contact details if anyone else was affected.

Any immediate action taken to mitigate this

Your recommendations or further comments

Is this incident *

One off

Ongoing

Would you like feedback? *

Yes

CLOSURE (FOR OFFICE USE only)

Tip: Who was this assigned to, and has the matter been closed to satisfaction of all parties.

St Columba Presbyterian Church at Botany | 480 Ti Rakau Road, Botany | PO Box 64136 Botany, Auckland 2163 | 09 274 4864