Incident Report Form

INCIDENT REPORT DATE OF OCCURRENCE:

TIME OF OCCURRENCE:

LOCATION: PERSON(S) INVOLVED NAME(S):

CUSTOMER

EMPLOYEE

TYPE OF INCIDENT (PLEASE CHECK THE APPROPRIATE BOX): FALL INJURY FAILURE TO FOLLOW ESTABLISHED PROCEDURE SECURITY ISSUE OR THEFT BEHAVIOR MANAGEMENT COMPLAINT OTHER: NARRATIVE OF OCCURRENCE: (ADD ADDITIONAL SHEETS IF NECESSARY):

REPORTED BY/SIGNATURE: WITNESSES: SUPERVISORY REVIEW AND RECOMMENDATIONS:

SUPERVISOR SIGNATURE: CAREER CENTER MANAGER REVIEW:

CAREER CENTER MANAGER SIGNATURE: ACTION TAKEN:

Revised by JT 9-26-16