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Incident Report

EMPLOYEE INFORMATION

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Full Name of Person Reporting Incident

Department

Date

Event

INJURED PARTY INFORMATION

Full Name of Person Impacted by Incident *

First

Last

Phone Number of Person Impacted by Incident

Email of Person Impacted by Incident

WITNESS INFORMATION

Witness Name *

First

Last

Witness Phone

Witness Email

INCIDENT DESCRIPTION

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Date and Time of Incident:

Date

Time

Location of Incident:

Type Of Incident

General Incident
Medical/Injury Incident

Police, Sheriff, EMT or Fire Department Present?

Describe The Incident (Be As Specific As Possible):

Upload Any Pertaining Photos

Click or drag a file to this area to upload.

INCIDENT MANAGEMENT ACTION

Incident Status

Alameda County Fairgrounds

Events and Fair (Directions)
2005 Valley Avenue
Gate 8 or 12
Pleasanton, CA 94566

Administrative Office & Deliveries
4501 Pleasanton Avenue
Pleasanton, CA 94566

Phone: 925-426-7600
Fax: 925-426-7599

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