Incident Report Form

Incident Report Form

Francis Frights LLC
This report is to be completed by the Manager responsible for the area where the alleged incident occured. All spaces must be filled out or the letters "N/A" (non-applicable) used. It may be necessary for more than one Manager to complete an Incident Investigation Report for a single incident. Thie report is only a preliminary report and must be used to create a Final Incident Investigation Report.
Incident Involving (mark all that apply)
Incident Type (mark one)
Location Name
Date of Incident

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Incident

Hour Minutes

AM/PM Option
Date this form was filled out

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Person involved in the Incident

First NameLast Name
Age of Person involved in the Incident
Legal Gender of Person involved in the Incident

Other
Describe the alleged incident or allegedly hazard/hazardous condition, etc. as claimed by the person(s) involved in the incident.
Exact Location (Scene, Position, Store, Queue, etc.)
Any resulting alleged injuries?
Act or condition which allegedly contributed to the incident as claimed by the person(s) involved in the incident:
Witness 1 Name

First NameLast Name
At least one witness needs to sign this form. If the person filling out this form happens to be the person who was also the first witness, they are able to sign.
Witness 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Witness 2 Name

First NameLast Name
Witness 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Witness 3 Name

First NameLast Name
Witness 3 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Manager first notified of the Incident:

First NameLast Name
Name of Person notifying the Manager:

First NameLast Name
Did the allegedly injured person receive emergency medical treatment?
If 'Yes', by whom?
If no, was medical treatment declined?
If medical treatment was declined, a signiture must be acquired by the person declining. If person is under 18, a parent or guardian's signiture must also be obtained.
Name of Person Declining Medical Treatment

First NameLast Name
By signing this form, I am declining medical attention by a physician or other medical providers at this time for the incident that I claim occurred at the location, date, and time listed above.
Name of Parent or Guardian

First NameLast Name
Parent or Guardian Signature (if person declining medical treatment is under 18).
If medical treatment was declined, was a signature received by the Person with the alleged injuries?
Transported to: blanks
By Whom: blank
Name of Manager responsible for area where incident occurred:

First NameLast Name
Do not sign until this form is complete.
I hereby state above facts are true to the best of my knowledge.
Should be Empty: