Incident Report Form - Confidential • NBC Central

This report must be completed if:

There is a minor or Critical Incident as per the Procedure for Responding to an Incident (Minor or Critical)
There is a Child Protection Concern as per the Procedures for Handlig Child Protection Concerns
There is a complainit made against a staff or volunteer as per the Procedures for Handling Complaints against staff and volunteers
Any other situations that you feel a record of the Incident occurring may assist in the future.

How do I complete this report?

Section 1 and 2 must be completed in all situations
Section 3 must be completed where there is an injury to an individual
Section 4 must be completed in relation to Child Protection concern
Section 5 must be completed in relation to a Complaint against staff and volunteers

Is there an injury to an individual? *

Is this in relation to Child Protection concern? *

Is this in relation to a Complaint against staff and volunteers *

Section 1 - Reporter Details

Date

First Name

Mobile Number

Did you witness the incident?

Role

Last Name

Email Address

Section 2 - Incident Details

Date of Incident *

Name of Program

Time of Incident *

Program Coordinator

Number of people injured

Full Name of first person injured (or in question)

Address of first person injured (or in question)

Contact number of first person injured (or in question)

Gender of person first injured (or in question)

Full name of second person injured

Address of second person injured

Contact number of second person injured

Gender of second person injured

List full names of other people injured

List addresses of other people injured

List contact numbers for other people injured

List gender(s) of other people injured

Section 3 - Injury Details

Give a brief description of what happened in this incident

Describe the details of the immediate treatment given

Who gave this treatment?

When were parents contacted?

Who contacted parents?

What was discussed with the parents?

Which emergency services were involved?

Give names of the hospital, doctor, or dentist visited

Please give details of any equipment, furniture or physical structures involved in this incident?

If this was a Critical Incident, who were the people involved in the decision making?

Person 1 Full name

Person 1 Role in the Church

Person 1 Phone

Person 2 Full name

Person 2 Role in the Church

Person 2 Phone

Person 3 Full Name

Person 3 Role in the Church

Person 3 Phone

Give details of the follow-up action required including the person responsible

Patient follow-up

Parents/care givers follow-up

Further instructions from authorities still to come

Counselling offered to leaders

Hazard removed

Reconsideration of activity

Potential media involvement

Insurance informed

Other

Signed and Dated by Ministry Coordinator

Signed and Dated by Governance Group member

Section 4 - Child Protection Details

Names of the Safe Spaces Team dealing with the allegation

SST 1 Full name

SST 1 Position in the Church

SST 1 Contact details

SST 2 Full name

SST 2 Position in the Church

SST 2 Contact details

SST 3 Full name

SST 3 Position in the Church

SST 3 Contact details

Describe the nature of the allegation and what occurred

If the assessment is that the child is in immediate danger, what actions have been put in place?

Is this a Mandatory Reporting offence?

000 contacted

Details of instructions given by Police and/or other Emergency Services

Instructions given

Please give details of immediate safety concerns of child and others considered

Give details of any support given to the person

If the assessment is that the child is not in immediate danger, however there is still a disclosure or suspicion of harm, have you contacted the Department of Child Safety, Seniours and Disabilities Services?

Department Contacted

If a report has not been made please outline how the Safe Spaces Team arrived at the decision that this was not considered reportable

How the decision was made

Signed and Dated by Senior Pastor

Signed and Dated by Safe Spaces Team member

Section 5 - Complaint about a staff or volunteer

Describe the complaint that has been made

What level is this considered?

Names of Governance Group dealing with the complaint

GG1 Full name

GG1 Position

GG! Contact details

GG2 Full name

GG2 Position

GG2 Contact details

GG3 Full name

GG3 Position

GG3 Contact details

Dealing with a Minor Complaint

Outline of meetings, discussions and outcomes

Dealing with a Major or Critical Complaint

Is the complaint a child protection concern

Tip: If yes you must also completed section 4

Is the complaint a crime?

Have Police been contacted?

If yes, give details of recommendations from Police

If no, detail reasons why authorities have not been contacted

Is there a possibility that government authorities, lawyers, or media might become involved?

Tip: If likely, an internal investigation is recommended. B Safe Spaces or the Professional Standards Officer within 48hrs of the incident occurring

Has the QB Safe Spaces Coordinator or Professional Standards Officer been contacted?

Document any recommendations from QB here

Outline details of the Risk Assessment performed by the Governance Group here

Provide details of the outcome of the complaint and who this has been communicated to

If an investigation has been initiated, either internally or externally, please email copies of these findings and subsequent decisions and outcomes made by Church Leadership to office@narangbaptist.org.au with CONFIDENTIAL in the subject

Signed and dated by Senior Pastor

Signed and dated by Governance Group member

A copy of this form and the emailed documents will be kept securely on file:

At the Church; and with
Queensland Baptists – confidentially available to the QB Safe Spaces Team, Baptist Insurance Scheme, Professional Standards or Pastoral Services as required.
Data collected from Incident reports will be reported to QB Directors and Board from time to time. Within these reports, church and personal details will remain anonymous, unless details are required to be released.

The QB Safe Spaces Coordinator will be in contact to follow up any further details, if required.