Church Incident Report Form

Church Incident Report Form

A church incident report is used to detail the particulars of an incident on church property. It includes a description of what happened and where, who was involved, and any actions taken to respond to the situation and prevent further occurrences. Once the form is complete, it should be kept in the church records for future reference.

Last updated August 21st, 2025

A church incident report is used to detail the particulars of an incident on church property. It includes a description of what happened and where, who was involved, and any actions taken to respond to the situation and prevent further occurrences. Once the form is complete, it should be kept in the church records for future reference.

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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

Download: PDF, MS Word, ODT

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

  1. Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [EMAIL] Address: [ADDRESS]
  2. Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [EMAIL] Address: [ADDRESS]

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:

  1. Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [EMAIL]
  2. 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

If yes, enter their name(s): [NAME(S) OF CHILDREN/YOUTHS]

Was the parent/guardian notified? Yes No

If yes, enter their name(s): [NAME(S) OF PARENTS/GUARDIANS]

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]