Crossroads Incident Report Form
PERSON COMPLETING FORM
First Name
Last Name
Ministry Position
Date
INCIDENT DETAILS
Type of Incident
Injury
Near Miss
Date of Incident
Specific Location
Time of Incident
REPORT
Reported By
Position
Reported To
Position
Date Reported
Time Reported
Reported to parent/guardian (name)
By Whom
Date
TREATMENT INFORMATION (only if injury occoured)
First Aid
Yes
No
Doctor
Yes
No
Ambulance
Yes
No
Details of alleged injury
Description of incident
NEAR MISS INFORMATION (Ony if near miss occoured)
Details of near miss
What, if any, immediate actions were taken to avoid a similar incident occuring?
Are there futher actions that need to be taken to avoid a similar incident in the future?
WITNESS INFORMATION
Witness 1
Full Name
Address
Contact Number
Email
Date of Birth
Witness 2
Full Name
Address
Contact Number
Email
Date of Birth
ACTION TAKEN
What action was taken?
Submit