Incident Report Form

Use this form to report accidents, injuries, medical situations, or behaviour incidents. Incidents involving a crime or traffic incident should be reported directly to the office.) If possible, the report should be completed within 24 hours of the events. Submit completed forms to the office.

Information about the Person Involved in the Incident

Full name

Address

Choose one

Mobile Phone

Home Phone

Information about the Incident

Date

Time

HoursMinutes

Police Notified

Address of Incident

Description of Incident (what happened, how it happened, factors leading to the event, etc) Be as specific as possible (attached additional sheets if necessary)

Witnesses

Were there any witnesses to the incident?

Yes, Witness Name

Witness Phone

Was the individual injured? If so, describe the injury (laceration, sprain, etc) the part of the body injured, and any other information known about the resulting injury(ies).

Was medical treatment provided?

If yes, where was treatment provided?

Notify Someone

Does the person involved wish to notify someone

If yes: Notify Name

Notify Phone

Reporter Information

Individual Submitting Report

Signature

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Date Report Completed