Refuge Church - Incident Report

Name of person completing this form

First Name

Last Name

Date of incident

MM

DD

YYYY

Event during which incident occured

Description of Incident

Were Outside Medical or Law Enforcement called?

If outside Medical or Law Enforcement were called:

Please provide more information: Who was called? Where did ambulance take affected parties? Police Report Number. Etc.

Name of Church Leader who was notified: