Incident Report Form • C3 New Hope

C3 New Hope Incident Report Form

Use this form to report any hazards, injuries, disclosures, or interpersonal concerns.
If you're unsure which category your report fits, click here to read definitions and examples.
Your report will be kept private and followed up by a relevant team member.

What are you reporting today?

A WHS hazard (e.g. unsafe environment or equipment)

A physical injury or medical incident

A disclosure or mandatory report (e.g. abuse, criminal concern)

A grievance or interpersonal concern

I'm not sure

WHS Hazard

Location

Specific location (room, area, etc.)

Tip: e.g. Kids Room, Auditorium stage, café kitchen, car park

Describe the hazard

Has the hazard caused an injury?

Yes

Is the hazard still present?

Yes

What action has already been taken to minimise the hazard?

Name of injured person

Date of incident

Time of incident

What happened? (Describe the incident and cause)

Tip: Include the nature of injury

First aid or medical attention given?

Who provided first aid?

Was a parent/guardian or next of kin notified?

Were other agencies or authorities notified?

Tip: this might be 000, hospital, DCJ, C3CS

Physical Injury or Medical Incident

Name of injured person

Location

Specific location (room, area, etc.)

Tip: e.g. Kids Room, Auditorium stage, café kitchen, car park

Date of incident

Time of incident

What happened? (Describe the incident and cause)

Tip: Include the nature of injury

First aid or medical attention given?

Yes

Who provided first aid?

Was a parent/guardian or next of kin notified?

Were other agencies or authorities notified?

Tip: this might be 000, hospital, DCJ, C3CS

Disclosure or Mandatory Report

Location

Date of disclosure

Who made the disclosure?

What was disclosed? (use their own words if possible)

Does this involve child safety or criminal concerns (e.g. DV, abuse, known offender)?

Has this been reported to a Ministry Leader or Campus Pastor? If so, who?

Have any immediate actions been taken?

Are there any supporting documents or images? If so, please email a copy to gm@c3newhope.com.au

Grievance or Interpersonal Concern

Location

Who is the grievance about?

Who are you submitting this on behalf of?

Summary of the concern

Is this related to a team, service, or church activity?

Would you like someone to follow up with you?

Preferred contact method (e.g. phone call, email)

I'm not sure

Location

Who did the incident happen to?

What happened? (in detail, describe the incident and cause)

Your First Name *

Your Last Name *

Your role or team *

Date of submission *

Who have you already told about this (if anyone)? *

Tip: this could be team leader, ministry leader, etc