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Incident/Accident Report

Name

*

Full Address

*

Phone Number:

*

Date of Birth:

*

Age

*

Type:

*

A

Employee

B

Patron

C

Visitor

Reason for being on premises:

*

Nature of Incident:

*

Accident/Injury

Physical Altercation

Property Damage

Theft/Burglary

Verbal Confrontation

Other (describe below)

Other Description:

*

Date of Accident/Incident:

*

Time of Incident:

*

Location of Incident

*

Specific Location of Accident/Incident (address/vicinity/actual location):

*

Accident/Incident occurred at:

*

Inside Venue

Outside Venue

Other Location (specify below)

Other Incident Location:

*

Briefly explain what happened:

*

What action was taken:

*

First Aid

Sent to Hospital

Pictures Taken (email to HR@5starstaff.com)

Sent Home

Investigation Started

Continued Activity (no action taken)

Please include any additional information:

*

Venue Contact/Management Name:

*

Venue Contact Phone:

*

Name of Witness

*

Witness Phone #:

*

Name of Person Completing Report:

*

Phone #:

*

Email

*

Please Note: Videos & photos are highly recommended immediately following an incident/accident. Please upload here:

*