Forms

Incident Report

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Date of accident/incident:

Time of accident/incident:

Reported to:

Person’s Name

Address

Phone

Witness Name: (Please include contact number)

Exact location where the accident/incident occurred:

Please provide a step-by-step how incident occurred:

If so, What was given?

By whom?

Was further assistance needed/offered? If so, please describe:

I AGREE: The above incident has been explained and discussed by Mercy Church personel. We agree and understand the incident described above. The information has been reported accurately, and to the best of our knowledge. *