Incident Report Form

Name of Reporter

Job Title

Address

Phone Number

Who does the incident relate to?

Staff Customer

Person(s) Involved

Date of Incident

Time of Incident

Location of Incident

Detailed description of Incident

Were there any witnesses? If so who? Please include their contact details.

Any medical attention received / required?

Was the incident escalated? If so to who? Please include their contact details.

Any additional information you wish to share: