Safer Churches - Incident/Near Miss Report • Breakthrough Church

INFORMATION ABOUT INCIDENT

TYPES OF INCIDENTS:

Incident involving injury

Note: This does not only include cases where Breakthrough is at fault – include all cases that take place on BCC property or at a BCC event.

eg. Two children clash heads and need ice applied to bumps in a Jumping Castle at BCC Family Day Event, A person injures their knee tripping over a vacuum cleaner.

Incident NOT involving injury

eg. A child gets a fright and wets themselves, a verbal fight in the carpark

A near miss

An incident where no-one is affected but someone could have been. The purpose is to help us improve our OHS.

eg. A worship team member trips over a cord on stage, An electric jug is knocked over in the kitchen spilling boiling water, A car carrying Youth to an event blows a tyre.

What type of incident was it?

Incident involving injury

Incident NOT involving injury

A near miss

Date of incident

Time of incident

Were Breakthrough authorities notified?

Yes

Location of incident

Description: (What happened, how it happened, factors leading to the incident, etc. Be as specific as possible)

Were there any witnesses?

Yes

Names and Mobile Numbers of witnesses

If a child was involved, were the parents/guardians notified?

Yes

Why weren't the parents/guardians notified?

INJURY REPORT

Describe the injury (laceration, sprain, etc), the part of the body injured, and any other information known about the resulting injury.

Was there medical treatment provided?

Yes

Patient refused

Where was the treatment provided?

On site

Ambulance/Hospital

Other

Please specify:

Provide the name(s) of those that provided the treatment.

OTHER INFORMATION

Please provide any further information you think may be helpful:

PERSON MAKING THE REPORT DETAILS

Enter your name *

Mobile Number

Today's Date *

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FOR OFFICE USE ONLY

Report received and filed by (Name):

Report received and filed (date):

FOLLOW UP ACTION OF INCIDENT

Document any follow up action taken after the incident (including both before and after Report)

Include items such as:

Insurance notifications/claims
Discussion with parents/guardians
Discussion with BCC Leaders and OHS/Safe Churches Representatives

Date

Action Taken

By Whom

REDUCING RISK

Document the Safety Team’s Discussion following this event, and what will be done to decrease the possibility of future occurrences:

(Include in description if decision is that this was a once off event, and no action will be taken)

Date	Action Taken	By Whom