Report Incident

OCCURRENCE REPORTS ARE REQUIRED FOR THE FOLLOWING:

(Listed as examples, only) Flooding, water damage or water disruption, injury to customers, comments by customers or nearby businesses, receipt of goods, equipment or fixtures, with shipping damage, fire, security violations, & employee Injuries. The general rule is, “when in doubt, fill one out”.

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Company Name:

Trade Name:

Contact Name:

Phone Number:

Email:

Incident Involves: Customer/Client Employee Volunteer Property Damage

Occurrence Date:

Occurrence Time:

Location of the Occurrence

Did the incident occur: Indoors Outdoors

Where specifically?

Describe the incident in detail:

Please provide a copy of the signed waiver.

Were there any witnesses? Yes No

Are you able to secure statements from the witnesses? Yes No

Please provide copy of the statements

Do you have videos of the incident?

Yes No Please provide us with a copy of the video.

Who were the people involved? (Complete all information below)

A. Full Name:

Age:

Gender:

How Involved?:

Address:

Phone Number:

Email Address:

B. Full Name:

Age:

Gender:

How Involved?:

Address:

Phone Number:

Email Address:

C. Full Name:

Age:

Gender:

How Involved?

Address:

Phone Number:

Email Address:

Did this incident involve an injury or an illness?

Yes No

What was the condition of the injured/ill party, when you arrived on the scene?

What is the actual injury?

Was First Aid administered? Yes No

If yes, who administered it?:

Was more than First Aid required? Yes No

If yes, describe

Was professional medical attention declined?: Yes No

If yes, who declined it?

Describe Medical attention given, if any:

Was injured/ill party taken to the Hospital?: Yes No

If yes, Name & Address of Hospital:

If the injured/ill party left on their own, did they say they will see a doctor? Yes No

If Yes, Name & Address of Physician:

What was the condition of the injured/ill person when they left your premises?:

 

Signature:

Title:

Date Submitted: