Incident Report

2. Your name:*

4. Today's Date:*

6. Date of Occurrence:*

8. Time of occurrence:*

10. Explanation: (Submit a separate page and turn it in if your text will not fit here)*

12. Persons involved: (names and phone numbers)*

14. Employees present:*

16. Were the police notified?*

    1. Yes
    2. No

18. Was the supervisor/director notified*

    1. Yes
    2. No

20. Damage or loss: List items stolen, lost, broken and their value.*

22. Individual(s) description: Information needed for future follow up by police or staff.*

24. Signature: Your supervisor will have you sign a copy this report.

Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field