Incident Report

This form should be used to report incidents such as accidents, health emergencies, and theft, etc. It should be completed as soon as possible following the incident. Staff members should follow-up to ensure that incident reports are received by the CEO or appropriate Department Head.

Person Involved in the Incident

If name is unknown and unknowable (for examples, the person is unconscious and alone or a shoplifter who has fled), please state "Unknown."
Please provide phone, email, and/or mailing address if known.

Description of Incident

Please be specific.
How the incident happened, factors leading to the event, and what took place. Be as specific as possible.
If yes, please provide their names and contact information below.

Actions Taken

Incident Information

If the cause(s) of incident are known, please describe them.

Reporter Information

This field is for validation purposes and should be left unchanged.