Digital Incident Report Form

Digital Incident Report

Private and Confidential
Event Location
Staff Name
Complainant Name
Do you have a preferred name you would like to be used?
Preferred Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
What is the best way to make contact? Voice, Text or Email?
2. Would you like something to cover up with like a blanket?
3. Water you like a bottled water?
4. Do you need a restroom visit being asked questions about the incident?
1. Do you give consent being asked question about what happened?
Authorized staff may continue to gather information about the incident from potential witnesses. If further action is required, any information gathered, including personal information, may be passed along to EMS and/or law enforcement to investigate.
2. Would you like the police contacted to handle this incident?
If a determination is made that a police report is needed, the local authorities will be contacted immediately by a staff member.
3. Do you want emergency medical services contacted?
If a determination is made that medical services are needed, EMS will be contacted immediately by a staff member.
4. Is there someone specific whom you authorize to receive information regarding this incident?
Information will only be shared with those authorized in this document to recieve it. Witnesses to the incident can only provide information about the incident to those authorized in this document.
Please provide the authorized persons name and contact information

Incident Details

Provide as much detail as possible
Do you know the name of the other person(s) involved? If not, please provide as much information as possible about them.
Describe in your words, as completely as possible, exactly what happened, as you perceived it. Please provide factual information including any conversations (if any), and the physical components of the incident that took place.
If there are any witnesses, please provide their name and/or contact information (if known).
Photo Upload: This should be used to upload identification (picture ID, event pass, etc, if available) of the participants and photos of injuries, if any.

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Confidentiality and Privacy Statement
Privacy and confidentiality is of the utmost importance. Information provided in this incident report will be limited to:
- Authorized staff
- Police or Medical personnel, should they be requested or deemed required.
- Any person authorized by you in this report to receive information.
The information provided is considered private and will be used solely for incident investigation and future prevention.

In order to maintain the privacy and sensitivity of those involved, discussion about this incident will be limited to those directly involved and/or authorized in this document. Discretion will be used when disseminating information about this incident.
Complainant Signature
Staff Signature
Time stamp/Location:
Should be Empty:

Digital Incident Report

Incident Details

Confidentiality and Privacy Statement