Incident Report

"*" indicates required fields

Date of Incident*

Location Incident Occurred:*

Off Site / Other Location:*

Time Incident Occurred or was First Noticed*

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

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

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

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

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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Max. file size: 256 MB.

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