INCIDENT REPORT TEMPLATE
2009
Introduction:
Complete a separate form for each incident, within 3 days of the incident occurring. Remember that failure to report an incident could result in someone else being put at risk in the future.
This form should be used for each occasion of:
Aggressive behaviour Verbal abuse Destruction of equipment or property (or threats of) Physical assault (or threats of)
Name of person completing the form: Last Name: _____________________________ First Name: __________________________ Position title: ___________________________ Date of incident: _________________________ Time: _______________ [Circle one] AM / PM Location of incident: _____________________________________ _____________________________________ _____________________________________
What was taking place when the incident occurred? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
Other persons present at the time: Last Name 1: ____________________________ First Name 1:_________________________ Last Name 2: ____________________________ First Name 2:_________________________ Last Name 3: ____________________________ First Name 3:_________________________ Last Name 4: ____________________________ First Name 4:_________________________
Name of perpetrator(s) if known, or description if unknown: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ _____________________________________________________________