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INCIDENT REPORT                                      REPORT DATE:


PERSON REPORTING INCIDENT:   


ADDRESS:    


PHONE NUMBER:   


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.

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Berkshire Athenaeum, Pittsfield's Public Library, Pittsfield, Massachusetts