Incident Report
Provide factual details only. Do not admit fault or assign blame.
Your Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Time of incident
Hour Minutes
AM
PM
AM/PM Option
Client Name / Address
Who was present?
Type of incident
Please Select
Property damage
Injury
Safety hazard
Client issue
Equipment issue
Other
Describe what happened
Be clear and factual. Do not assume or guess.
What caused the issue?
Was anyone injured?
Yes
No
(If yes) Who was injured?
(If yes) Was medical attention needed?
Yes
No
What did you do?
Was management contacted?
Yes
No
Was anything damaged?
Yes
No
(If yes) What was damaged?
(If yes) Estimated severity:
Minor
Moderate
Major
Photos
Browse Files
Drag and drop files here
Choose a file
Upload photos of: damage, area, equipment (if relevant)
Cancel
of
Does this require a follow up?
Yes
No
Additional notes
Submit
Should be Empty: