Incident Report Incident Report Date of Incident* MM slash DD slash YYYY Location Incident Occurred:*--Select--Code One AllentownCode One Boston / WoburnCode One CharlestonCode One East HartfordCode One New Haven / WoodbridgeCode One PhiladelphiaCode One Portland / BiddefordCode One SavannahCode One WillimanticCode One WorcesterOff Site / Other LocationOff Site / Other Location:*Time Incident Occurred or was First Noticed* : Hours Minutes AM PM AM/PM Teammate Reporting Incident* First Last Name(s) and Phone Number(s) of Involved Person(s)First NameLast NamePhone Number Name(s) and Phone Number(s) of Witness(es)First NameLast NamePhone 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: Drop files here or Select files Max. file size: 256 MB. Suggested Follow Up Actions:
