Incident/Maintenance Form

Incident & Maintenance Request Form

For all medical emergencies please call 9-1-1

Generator's top priority is member safety and security. Thank you for taking the time to report an incident or maintenance request so that it can be addressed.

Filling out this form sends an email alert to multiple staff members. A staff member will follow-up with you as soon as possible, usually within 1-3 business days.

Name*

First NameLast Name
Email*
example@example.com
What are you reporting?*

Tool/Facility Maintenance - Broken Tools/Shop Needs/Etc.Injury or Medical IncidentMember Incident - Unsafe/Unacceptable BehaviorOther
Please note that "Tool/Facility Maintenance" and "Injury or Medical Incident" reports are sent to all Generator staff. However, "Member Incidents" are only sent to the director team: Meg, Veronica and Mason. If you'd feel more comfortable contacting them directly, please feel free to do so:
- Meg Hammond: director@generatorvt.com
- Veronica Newton: veronica@generatorvt.com
- Mason Merriam: mason@generatorvt.com

Member Incident
Date of Incident*

MonthDayYear
Date
Time of Incident*

Hour Minutes

AM/PM Option
What kind of incident are you reporting?*

Verbal Conflict or DisagreementHarassmentUnsafe Member ActivityQuestionable Member Status &/or Tool CertificationOther
Please describe the incident:*
Do you have a suggested course of action?*
If you have any sort of documentation to help explain the incident, please attach it here:

Cancelof

Injury or Medical Incident
Date of Incident*

MonthDayYear
Date
Time of Incident*

Hour Minutes

AM/PM Option
What kind of incident are you reporting? (Check All that Apply)*

InjuryMedical IncidentOther
Please write a short narrative describing the incident:*
What action was taken to manage the situation? Please be as specific as possible.*
Do you have a suggested course of action or follow up?*
If you have any photos or video that will help explain the incident, please attach them here:

Cancelof

Tool/Facility Maintenance