Incident Report

Date of Incident*
MM slash DD slash YYYY
Location Incident Occurred:*
Off Site / Other Location:*
Time Incident Occurred or was First Noticed*

: Hours

Minutes

AM/PM
Teammate Reporting Incident*
First Last
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:*
Upload related files, photos, or videos:
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Max. file size: 256 MB.
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