Incident Report Incident Report Date Incident Occurred*Use today's date if unknown. Time Incident Occurred*Use reporting time if unknown. : HH MM AM PM Employee Reporting Incident* First Last Name and Phone Number of Involved Party or Parties (if known):Name and Phone Number of Witness(es):Did incident result in illness or bodily injury to any staff?*SelectYesNoHas a workmans compensation claim been made to report incident?*SelectYesNoDetails of workmans compensation claim:Include date/time of notification, case number, and any additional pertinent information.Did incident involve bodily injury or illness to a non-employee of Code One (i.e. customer or bystander)?*SelectYesNoWas first aid rendered to the ill or injured party?*SelectYesNoDescribe care that was rendered and who provided care:Were emergency services (police, fire, EMS) notified of this incident?*SelectYesNoDetails of emergency services:Include date/time of notification, case number, responding agencies, and disposition (i.e. patient transported to Memorial Hospital).Was the ill or injured party or parties advised to seek follow-up care at a medical facility?*SelectYesNoDetails of referral:Please indicate any details about instructions given to party or parties regarding follow-up care, how many times they were advised to seek care, and if they planned to seek follow-up care or refused.Did incident result in damage to property?*SelectYesNoProperty damage details:Describe damaged property, owner of the property (if known), and estimated cost to repair or replace:Incident Report:*Be as objective and descriptive as possible.Upload related files, photos, or videos: Drop files here or Suggested Follow Up Actions (if any):*
