"Incident Report Form"

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INCIDENT REPORT
Property Name: _______________________________________________
Property Location Address: _____________________________________
Name of Person Injured: _____________________________________
Address – Home: ______________________________________________
Street
City
State
Zip
Business: _______________________________________________
Street
City
State
Zip
Telephone # : Home ( ___ ) ___________________
Business #: ( ___ ) ____________________
Property Contact: _________________________________
Date of incident: _______________________ Time of incident: _________________
A.M. or P.M.
Month
Date
Year
Date incident reported: ___________________ Time incident reported: ____________
A.M. or P.M
Month
Date
Year
Person injured or affected: – ____Guest or ____ Non- guest or ____ Hotel employee
If Guest: Check-in date: __________ Time:__________ Room: __________
If non-guest : purpose of hotel visit : ______________________________________
Thorough description (include: incident, nature of injury, material damages, outcome, etc. )
Location of incident:
INCIDENT REPORT
Property Name: _______________________________________________
Property Location Address: _____________________________________
Name of Person Injured: _____________________________________
Address – Home: ______________________________________________
Street
City
State
Zip
Business: _______________________________________________
Street
City
State
Zip
Telephone # : Home ( ___ ) ___________________
Business #: ( ___ ) ____________________
Property Contact: _________________________________
Date of incident: _______________________ Time of incident: _________________
A.M. or P.M.
Month
Date
Year
Date incident reported: ___________________ Time incident reported: ____________
A.M. or P.M
Month
Date
Year
Person injured or affected: – ____Guest or ____ Non- guest or ____ Hotel employee
If Guest: Check-in date: __________ Time:__________ Room: __________
If non-guest : purpose of hotel visit : ______________________________________
Thorough description (include: incident, nature of injury, material damages, outcome, etc. )
Location of incident:
Page 2
Name: (injured party) __________________________________ Date: ______________________
Was a vehicle(s) involved ______ No ______Yes – Make & Model: _______________________
Year: ________
Where was vehicle parked? ___________________________________
Medical treatment required: _______ No ________Yes - Medical Facility : __________________
Did emergency officials respond? _______ No ________Yes
Is this incident being investigated by authorities ? _______ No ________ Yes
Officer’s name/affiliation:_________________________ Case#: ___________________________
Did anyone involved in this incident threaten a lawsuit ? ______ NO ______ Yes - Provide Details:
Witness(es):
Name: ___________________________ Phone #: (______)_____________________
Name: ___________________________ Phone #: (______)_____________________
Name: ___________________________ Phone #: (______)_____________________
Current status of situation / outcome of the incident :
Person completing report: ____________________________________Date: __________________
Print name:_______________________________________________________________________
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