Incident Report

Name(s) and Phone Number(s) of Involved Person(s)

First Name	Last Name	Phone Number

Name(s) and Phone Number(s) of Witness(es)

First Name	Last Name	Phone Number

Did incident result in illness or bodily injury to any staff?*
- Yes
- No
Staff Injury or Illness Description:*
Include name(s) of injured or ill staff members, description of illness or injury, and whether they have sought treatment. Notify Manager on Call at 860.786.1789 ext 99.
Did incident involve bodily injury or illness to a non-employee of Code One (i.e. customer or bystander)?*
- Yes
- No
Non-Staff Injury or Illness Description:*
Include name(s) of injured or ill person(s), description of illness or injury, and whether they have sought treatment. Notify Manager on Call at 860.786.1789 ext 99.
Were emergency services (police, fire, EMS) notified of this incident?*
- Yes
- No
Agency Information:*
Please include the names of responding service(s) and incident number(s) if available. Photograph and upload below copies of any incident reports.
Did incident result in damage to property?*
- Yes
- No
Property Damage Information:*
Describe property damage. If known, include how damage occurred and name of property owner. Remove any unsafe equipment from service and label it out of service. Upload photograph of damaged property below.
Describe Incident:*
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