Critical Incident Report Form
Incident Details:
Date of Incident:
*
/
Day
/
Month
Year
Time:
*
Hour Minutes
AM
PM
AM/PM Option
Location:
*
Injured/Concern Person Name:
*
Email Address:
*
Phone Number:
*
Address:
*
Name of person filling in this report:
*
Details of the incident:
*
Describe the Injured/Concern:
*
Please outline the steps taken to treat the Injured/Concern:
Please identify any hazards that may have contributed to or caused the Injured/Concern:
Other notes and comments:
Take Photo
Take Photo
Take Photo
Upload Photo/Video: (If any)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Injured/Concern person’s signature:
Injured/Concern person Name:
*
Date:
*
/
Day
/
Month
Year
Signature of Person filling in this report:
Your Name:
*
Date:
*
/
Day
/
Month
Year
Submit
Should be Empty:
