7900 SW 176th Street, Palmetto Bay, FL 33157 www.palmertrinity.org – 305.252.2230
INCIDENT REPORT INCIDENT TYPE / DESCRIPTION:____________________________________________________________ LOCATION:______________________________________________________________________________ DATE OF INCIDENT:______________ TIME OF INCIDENT: ______________ Police Rpt #______________
NARRATIVE OF INCIDENT: (Explain in detail, WHO, WHAT, WHEN, WHERE, WHY and HOW…circumstances and cause of the incident) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ ACTION TAKEN: (Who investigated? Who was notified? Who was present pre/at/before the incident? Was situation corrected? Video/Pics?) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
COMMENTS AND RECOMMENDATIONS: (Further action required? How can future incidents be prevented?) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
PREPARED BY NAME / SIGNATURE: _______________________________________________
DEPARTMENT: __________________________
SUPERVISOR’S NAME / SIGNATURE: ________________________________________________________ DATE: __________________________