Incident Report

EMPLOYEE INFORMATION

Full Name of Person Reporting Incident

Employee Or Non-Employee *

Event

Department

Date

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

Date and Time of Incident:

Date

Time

Location of Incident:

Type Of Incident

Police, Sheriff, EMT or Fire Department Present?

Describe The Incident (Be As Specific As Possible):

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INCIDENT MANAGEMENT ACTION

Incident Status

Contact Info