Incident / Accident Report Name of Department or Organization Name of person in charge: Location incident/accident took place: Date of incident/accident: Time of incident/accident: Name of injured person: Damage of facility or property: Address of injured person: If applicable, name of witness: Nature of incident/accident: Is this a Clery Act incident?YesNo Give details of how and precisely where the incident/accident took place. Give full details of the action taken including any first aid treatment and the name(s) of the first aider(s): Were any of the following contacted: Police:YesNo Ambulance:YesNo Director/Assistance of Public Safety:YesNo What happened to the injured person following the incident/accident? (eg went home, went to hospital, carried on with session) Additional Comments: By checking this box:I confirm that all of the above facts are a true and accurate record of the incident/accident. Full Name: Date:
