Critical Incident Report Form
Incident Details:
Date of Incident:
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Time:
*
Hour Minutes
AM
PM
AM/PM Option
Location:
*
Injured/Concern Person Name:
*
Email Address:
*
Phone Number:
*
Format: (000) 000-0000.
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:
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Injured/Concern person’s signature:
Injured/Concern person Name:
*
Date:
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Signature of Person filling in this report:
Your Name:
*
Date:
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Submit
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