Accident Report

 

An Accident Report should be completed for any incident resulting in injury (whether minor or major) occurring on the property of Saint Elizabeth Ann Seton Catholic Church or any offsite activity that is sponsored by Saint Elizabeth Ann Seton Catholic Church. This report should be completed within 24 hours of the incident.  

If you have any questions, please contact the Business Manager in the parish office.

Information About Person Reporting Accident
Name
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Phone --
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Email
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Information About Person Injured
Name
  •  
Date of Birth //
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List (Single Choice)
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*If Minor, Parent Name
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Phone -- ext
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Alternative Phone -- ext
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Address
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Was Person Transported by Ambulance?
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Witness Information
Please complete this section if there is a witness to the accident.
Name
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Phone -- ext
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Address
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Additional Witnesses
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Please list the names, telephone numbers, and addresses of any additional witnesses.
Accident Information
Date of Accident //
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Time of Accident
: 
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Place of Accident
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Type of Event
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*If Parish Event, Name of Event and/or Leader Information
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Description of Accident
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Description of Injury/Damage
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Were Photographs Taken of Accident?
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Comments
Please write any other comments below.
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  •  
 
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