MLUC Incident Report Form
Please fill out this form and click submit.
Who is filing this report and when?
Date this report is being filed
*
Time this report is being filed
*
Name of individual filing this report
*
Role/Title (eg. usher, staff, etc.)
*
Phone
*
Email
*
This address will receive a confirmation email
When and where did this incident happen, and what happened?
Date of incident
*
Time of incident
*
Specific location of incident (eg. elevator, front parking lot, kitchen, etc.)
*
Type of incident (check all that apply)
*
Please select all that apply.
Personal Injury / Medical Emergency
Property Damage / Vandalism
Theft / Missing Property
Behavioral / Security Issue
Child Safety Incident
Other (see below)
If you checked "other" above, please explain
Who was involved?
Name of person involved in the incident
*
Is this person ...
*
Please select all that apply.
A member?
A visitor?
attending an event managed by another organization here at MLUC?
A volunteer?
A staff member?
An adult?
A child or teen?
If this person is a minor, parent or guardian's name:
Phone
Email
Were there other individuals involved in what happened? If so, please provide the information collected above for these individuals as well, here:
Description of incident
Please provide a factual, objective description of what happened. Avoid speculation or assumptions.
*
Followup
Were there any witnesses (not directly impacted by the incident)? If so, please list their names, phone numbers, and email addresses here:
Was first aid rendered?
*
Please select one option.
Yes
No
I don't know
If first aid was rendered, who provided care?
Was 911 called?
*
Please select one option.
Yes
No
I don't know
If 911 was called, who did so?
Did emergency services respond?
*
Please select one option.
Yes
No
I don't know
If emergency services responded, please list officer's names and badge numbers
Did any injured individual refuse medical treatment?
*
Please select one option.
Yes
No
I don't know
If someone refused medical treatment, who was it?
Who was notified? (Choose all that apply.)
*
Please select all that apply.
A Minister of the church
Another church staff member
A lay leader in the church
Parent/Guardian of any child involved
Other/N/A
Please list names of all those so notified (above)
Submit
Description
Please fill out this form and click submit.
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