Incident & Near Miss Form

This form is for reporting any injury, incident, or near miss. Please note that you may be contacted to clarify or provide further details if needed. All information given is treated in the strictest of confidence and is used in accordance with the LifeHouse Privacy Policy.

Your Details (the person filling in this form)

First Name *

Mobile Number

Last Name *

Email Address

Details of the Injury, Incident, Near Miss or Unusual Behaviour

Details (be specific) *

Names of the people/person involved (if known)

Date it occurred

Time it occurred

Name of the Pastor, staff member or Leader you reported this to

Where did it occur

North Campus

Other

Specific Location (e.g. carpark, kitchen)

Detail any immediate action taken