Incident Report

Incident Report
Choose type of incident/injury being reported
Location submitting report*
Person writing report*

First NameLast Name
Person writing report email*
example@example.com
Location requesting write off of bad debt*
Person requesting write off of bad debt*

First NameLast Name
Customer Information*
Customer e-mail
example@example.com
Witness e-mail
example@example.com
Date of incident*

MonthDayYear
Date
Hour MinutesAM/PM Option
Date of injury*

MonthDayYear
Date
Hour MinutesAM/PM Option
Location incident occurred*

Street Address

CityState / Province

Postal / Zip Code
Location injury occurred*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Detail where injury occured.*
e.g. concrete plant, work shop, on delivery, wash bay, propane tank, ect.
Detail type of injury that was sustained.*
e.g. right wrist, left elbow, lower right back, etc.
Customer(s) renting from All Star Rents*
Employee(s) involved in incident*
Customer phone number*
Phone Number
Has equipment been quarantined?*

YesNo
Equipment Involved*
Equipment used at time of injury
Person(s) injured*
Person(s) Injured Customer(s) & Employee(s)*
Did the injured receive medical treatment?
At what medical institution did they receive care?

Medical Facility

Street Address

CityState / Province

Postal / Zip Code
Please detail treatment
Please detail why treatment was not needed
Was a police report filed?
Agency incident was reported to
Please explain why no police report was filed
Employee was drug & alcohol tested on.

MonthDayYear
Date
Hour MinutesAM/PM Option
All Star Rents Manager or Supervisor statement
Describe the incident, in full detail (who, what, where, when, how, etc)
Employee involved in incident statement
Describe the incident, in full detail (who, what, where, when, how, etc)
Should be Empty: