INCIDENT REPORT REPORT DATE:
PERSON REPORTING INCIDENT:
WHEN DID THIS HAPPEN? (DATE & HOUR)
WHERE DID THIS HAPPEN?
DESCRIBE WHAT HAPPENED:
PERSONS INVOLVED (Names and addresses if known):
WITNESSES (Names and addresses if known):
EMPLOYEE REPORTING INCIDENT (if different from above): _____________________________
(Provide administration with original report, keep copy for departmental file)
Updated December 2010.