Incident Reporting Form.pdf

Return this form to Safety Coordinator within 24 hours of incident.

 

 

Date of incident:  _______________  Time:  ________ AM/PM

 

Name of injured person:                                                                                                         

 

Address:                                                                                                                                 

 

Phone Number(s):                                                                                                                  

 

Date of birth:  ________________     Male ______            Female _______

 

Who was injured person?(circle one)      Passenger                        System Employee

 

Type of injury:                                                                                                                        

Details of incident:                                                                                                                 

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

 

Injury requires physician/hospital visit?           Yes ___      No _____

 

Name of physician/hospital:                                                                                                   

 

Address:                                                                                                                                 

 

Physician/hospital phone number:                                                                                          

Signature of injured party _______________________________________Date

 

 

*No medical attention was desired and/or required.

                                                                                                                                    _______

 

 

Signature of injured party                                                                                Date