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Belmont Assembly Of God Incident & Accident Report

Instructions

1. This form shall be completed by Belmont Assembly of God staff, elders/deacons or ministry leadership whenever anyone in attendance at or on the premise of Belmont Assembly of God is involved in an incident or accident which resulted in personal injury or property loss - EXCEPT for occupational (worker's compensation reportable) or automobile related accidents.

2. Upon completion of this form, submit to the church office for further review and disposition.

Your name *

Last name

Email address *

GENERAL INFORMATION

Name of Person Affected by Incident/Accident *

Sex *

Male

Female

Age *

min: 0 / max: 100

Address *

Home Phone

Work Phone

Cell Phone

Status *

Staff

Worker

Member

Visitor/Guest

Date and Time of Incident or Accident *

Exact Location Where Incident or Accident Occurred *

Witnessed By (Name) *

Witness Phone No./Contact Info (Cell, email) *

PERSONAL INJURY RELATED INCIDENT OR ACCIDENT DETAILS

Describe how the incident/accident occurred in full detail (what led up to the accident or injury). Also - identify the individual(s) who may have caused or contributed to the incident/accident. *

Reported to Chicago Police? *

Yes

No

Police Report Number Assigned

Apparent Nature of Injury *

Parts of Body Injured *

Describe Immediate Action Taken *

By Whom? *

Explain any First Aid given *

By Whom? *

If taken to hospital/clinic - method of transportation?

Attending Physician

Hospital/Clinic

PROPERTY DAMAGE OR THEFT RELATED INCIDENT DETAILS

Exact Description of Loss

Describe Property in Detail

Approximate Dollar Value

Reported to Chicago Police?

Yes

No

Police Report Number Assigned

Damage or Theft Reported By?

Phone No.

ADDITIONAL INFORMATION

PERSON COMPLETING THIS REPORT *

Date Completed *

Phone No. *

Email Address *

Complete This Section if a Minor (Child Under 18 Yrs. of Age) was Involved in the Incident/Accident

Parent/Guardian Notified?

Yes

No

By Whom?

How?

Name of Parent/Guardian

Date Notified

Any Additional General Comments or Information

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Belmont Assembly of God
findingdirection@belmontag.org
773-725-2116

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