LIFE CHAPEL INCIDENT REPORT • Life Chapel

Full Name of Child *

Date of incident/injury occurred *

Date of Birth

Time incident occurred

Circumstances of incident/injury:

Location where incident/injury occurred: *

Nature of any injury sustained:

Action taken, including administration of first aid:

Time of child's departure from centre:

Name of person collecting the child:

Record of persons notified and by whom:

Name of person making the report: *

Signature of person making the report: *

I/we acknowledge that I/we have been notified of the incident/injury:

Signature of parent/s:

Action has been taken to address risk (as relevant):

YES

NOTE: Life Chapel MUST retain a child's incident or injury report form for 1 year from the time of the incident.

Follow-up/Action taken: