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Employee Incident Report
Location*
location other expalin
Report Number
Choose One:*
This is an Actual Report
This is a Training Report
Date of Incident:
Your Name*
Other Employees:*Others on duty?
Call Supervisor?*
Yes
No
If necessary per proper Policy
General Incident Report Information
Description*Full details/include location
Who Reported the Incident?
Report Number
Who Reported Incident?*
Employee
Tenant
Other, explain:
Full details/include location
Space #
Full Name
Address Line 1:
Address Line 2:
City-State-Zip
State:
Zip Code:
Home Phone:
Business Phone:
Cell Phone:
E-Mail:
Emergency Services
Were emergency services needed?*
Yes No 
Report Number
Was 911 dialed?*
Yes No 
Were Police On-site?*
Yes No 
Was Fire Department On-Site?*
Yes No 
Emergency Medical/Paramedics On-Site?*
Yes No 
Emergency Elevator Service or Rescue?*
Yes No 
Specify Other Services/Details
Witnesses Information
Are there witnesses?*
Yes No 
Report Number
Witness:*
Employee
Tenant
None
Other, explain:
Full Name:
Address Line 1:
Address Line 2:
City-State-Zip
State:
Zip Code:
Home Phone:
Business Phone:
Cell Phone:
E-Mail:
Injuries Information
Are there injuries?*
Yes No 
Report Number
Injuried Employee?
Yes
No
Work Related?
Yes
No
Unknown
Injuried Fulled Name:
Address Line 1:
Address Line 2:
City-State-Zip
State:
Zip Code:
Home Phone:
Business Phone:
Cell Phone:
E-Mail:
DescriptionFull details/include location
Property Damage Information
Is there property damage?*
Yes No 
Report Number
Whose Property was involved?*
Company Property
Employee Property
Tenant Property
No Property was involved
Other, explain:
Full details/include location
Space #
Full Name:
Address Line 1:
Address Line 2:
City-State-Zip
State:
Zip Code:
Home Phone:
Business Phone:
Cell Phone:
E-Mail:
DescriptionFull details/include location
Auto Related Accident/Incident Report Information
Was this an auto related accident?*
Yes No 
Report Number
Injuried First Name:
DL #
DL State
DL EXP Date
Vehicle Lic #
Veh Lic State
Veh Lic Exp Date
Vehicle Make
Vehicle Model
Vehicle Color
Address Line 1:
Address Line 2:
City-State-Zip:
State:
Zip Code:
Home Phone:
Business Phone:
Cell Phone:
E-Mail:
DescriptionFull details/include location
Certification and Filing Instructions
I certify that the information that is contained in this report is true and accurate.
Signature:* fill in your name
Reset 
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