SAMPLE INCIDENT REPORT FORM

LOCATION

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Date of incident

Day of week

Time

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.....

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EMPLOYEE

Name

Address

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.....

.....

Job/grade

Department

Other Details

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.....

.....

.....

What activity were you engaged in at the time of the incident?

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DETAILS OF ASSAILANT(S)

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WITNESS(ES)

Name

.....

Name

.....

Name

.....

Address

Address

Address

.....

.....

.....

.....

.....

.....

.....

Age

.....

Age

.....

Age

.....

M/F

.....

M/F

.....

M/F

Details

Details

Details

Give account of incident

Injury

.....

Verbal abuse

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Anti-social Behaviour

.....

Time Lost?

.....

.....

Time Lost

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Damage to property

.....

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Were The Police Called? Security Investigated Incident? Name Of Investigator?

Details Regarding Location Of Incident ( Provide Sketch If Possible)