Church Incident Report Form

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Church Incident Report Form

A church incident report is used to detail the particulars of an incident involving one or more people on church property. Completing the form may provide security and act as evidence against claims from involved parties. Keeping a record of incidents on church property also helps keep track of staff and clergy members.

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Last updated August 1st, 2025

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A church incident report is used to detail the particulars of an incident involving one or more people on church property. Completing the form may provide security and act as evidence against claims from involved parties. Keeping a record of incidents on church property also helps keep track of staff and clergy members.

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Incidents That Should Be Recorded

  • Physical and verbal altercations
  • Injuries and medical emergencies
  • Damaged or stolen property
  • Unlawful activity (drugs, weapons, etc.)
  • Problems with children or nursery staff

Sample

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CHURCH INCIDENT REPORT FORM
INCIDENT DETAILS
Date of Incident: [DATE OF INCIDENT]      Time: [TIME] ☐ AM ☐ PM

Church Name: [CHURCH NAME] Location: [LOCATION]

Describe the Incident: [DESCRIBE THE INCIDENT]

PARTIES INVOLVED
Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [EMAIL] Address: [ADDRESS]

Identification: ☐ Driver’s License No. [DL NUMBER] ☐ Passport No. [PASSPORT NUMBER] ☐ Other: [OTHER]

INJURIES
Was anyone injured? ☐ Yes ☐ No If yes, describe the injuries: [INJURY DESCRIPTION]

WITNESSES
Were there witnesses to the incident? ☐ Yes ☐ No

If yes, enter the witnesses’ names and contact info:

Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [EMAIL]

PARENT/GUARDIAN NOTIFICATION
If children or youths are involved in the incident, their parents or guardians must be notified.

Were children or youths involved in the incident? ☐ Yes ☐ No

Was the parent/guardian notified? ☐ Yes ☐ No

Name of person who contacted parent/guardian: [NAME OF PERSON]

Staff person in charge at time of incident: [NAME OF STAFF PERSON]

POLICE/MEDICAL SERVICES
Police Notified?☐ Yes ☐ No If yes, was a report filed? ☐ Yes ☐ No

Was medical treatment provided? ☐ Yes ☐ No ☐ Refused

If yes, where was medical treatment provided? ☐ On site ☐ Hospital ☐ Other: [OTHER]

INDIVIDUAL FILING REPORT

Full Name: [FULL NAME] Title/Role: [TITLE/ROLE]
Signature:                                                           Date: [MM/DD/YYYY]