Employee Incident Report

Location*
		location other expalin
Report Number
Choose One:*	This is an Actual Report This is a Training Report
Date of Incident:*
Your Name*
Other Employees:*		Others on duty?
Call Supervisor?*	Yes No	If necessary per proper Policy
General Incident Report Information
Description*		Full details/include location
Who Reported the Incident?
Report Number
Who Reported Incident?*	Employee Tenant Other, explain:
		Full details/include location
Space #
Full Name
Address Line 1:
Address Line 2:
City-State-Zip
Home Phone:
Business Phone:
Cell Phone:
E-Mail:
Emergency Services
Report Number
Was 911 dialed?*	Yes No
Were Police On-site?*	Yes No
Was Fire Department On-Site?*	Yes No
Emergency Medical/Paramedics On-Site?*	Yes No
Emergency Elevator Service or Rescue?*	Yes No
Specify Other Services/Details
Witnesses Information
Report Number
Witness:*	Employee Tenant None Other, explain:

Full Name:
Address Line 1:
Address Line 2:
City-State-Zip
Home Phone:
Business Phone:
Cell Phone:
E-Mail:
Injuries Information
Report Number
Injuried Employee?	Yes No
Work Related?	Yes No Unknown
Injuried Fulled Name:
Address Line 1:
Address Line 2:
City-State-Zip
Home Phone:
Business Phone:
Cell Phone:
E-Mail:
Description		Full details/include location
Property Damage Information
Report Number
Whose Property was involved?*	Company Property Employee Property Tenant Property No Property was involved Other, explain:
		Full details/include location
Space #
Full Name:
Address Line 1:
Address Line 2:
City-State-Zip
Home Phone:
Business Phone:
Cell Phone:
E-Mail:
Description		Full details/include location
Auto Related Accident/Incident Report Information
Report Number
Injuried First Name:
DL #
DL State
DL EXP Date
Vehicle Lic #
Veh Lic State
Veh Lic Exp Date		Date of written report
Vehicle Make
Vehicle Model
Vehicle Color
Address Line 1:
Address Line 2:
City-State-Zip:
Home Phone:
Business Phone:
Cell Phone:
E-Mail:
Description		Full details/include location
Certification and Filing Instructions
I certify that the information that is contained in this report is true and accurate.
Signature:*		fill in your name
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