PCQ WHS Incident Notification • Presbyterian Church of Queensland

Purpose

This form is for the recording of Workplace Injuries or Near Misses on Church property or at Church events/activities. This includes trips, falls, accidents, etc.

Incident Summary

Describe the incident in the fields below. For more information refer to the Incident Notification Procedure.

Incident Description *

Incident Location *

Incident Category *

Incident Date *

Incident Activity *

Tip: Enter the name of the Activity, Event or Program at which the Incident occurred

Incident Time

Incident Congregation *

Tip: Enter the name of the Charge whose Session approved the Activity at which the Incident occurred

Person Directly Affected

Last Name

First Name

Congregation

Status

Date of Birth

Phone Number

Email Address

Incident Details

Sequence of Events before the Incident

Injuries Sustained

People Involved

Vehicle Involved

Immediate Actions Taken

First Aid Provided

Emergency Services Involved

Medical Treatment Provided

Incident Notifier Name

Incident Notifier relationship to this incident notification

Incident Notifier Phone