Nativity Incident Form

NATIVITY CHURCH

* Indicates required field

Time of incident *

Date *

Name of the person filling in this form *

First

Last

Email *

Did this incident occur at a Nativity church event or on Nativity property? *

Yes No

Incident discription *

The general nature of damage/injury *

Physical Emotional/mental Property

please check one or more

Please list any important names and contact details related to the incident here *

Follow up actions (what was done in response e.g. first aid applied, ambulance called, family contacted, vicar contacted etc) *

Is there anything that could be done to avoid this happening in future? *

This inccident has been reported to: *

Police Ambulance The vicar The wardens Fire Department The family/whanau Social agency Nativity staff, using this form Other

If other please discribe *

Signature *

(by typing your name in the box above you agree that this is a true and accurate record of events)

Date *

Once you submit this form Nativity staff will seek to be in contact promptly to follow up about the incident. Thank you.

Submit

United in Christ: Drawing in, Growing Up, Reaching Out

Nativity Church
P: 03 578 3909 E: info@nativity.org.nz A: 76 Alfred St, Blenheim 7201