Maybe the others on the site will post the Incident Reports that they use so that we can compare them.

The XXXX Club
Initial Incident Investigation Report

Part One: Initiation-To be completed by the Person Involved in the Incident.

Name of the Incident Initiator (please print):_________________________
Employer (if other then XXX Club):____________________________________
Report Start Date:___________Time Report Started:_________am/pm
Date of Incident:____________Time of Incident:____________am/pm

Part Two: Incident Details-To be completed by the Initiator.

Type of Incident (check all that apply): __Injury __Fall __Altercation
__Fire __Cut __Assault
__Theft from Employee __Theft from Customer __Other (specify)_________

Location of Event:____________________________________________ ____________

Known Injuries (list all injuries by victim):_____________________________________

__________________________________________________ ______________________
Witness(s) (list name, address and relationship to the parties involved):_______________

Medical Attention Provided: ___Yes ___No
___First Aid ___Hospital Admission

Police Department Assistance: ___Yes___No Officers Name:_________________
Police Report Tracking Number:___________________________________________

Incident Details (describe the incident, in your own words, circumstances leading up to the incident, what happened during the incident, what happened after the incident and any other pertinent information):_____________________________________ ___________

Part Three: Supervisory/Incident Commander Review-To be completed by the Facility Supervisor or the Incident Commander.

Signature of Supervisor/Incident Commander:_________________________________
Date that the Report was Received:_____Time that the Report was Received____am/pm.

Describe the steps taken to preserve evidence (if required):________________________

Describe any and all initial actions taken to prevent a recurrence of the incident:_______

__________________________________________________ ______________________

Part Four: Level of the Incident (check all that apply):
__Level 1 (death)
__Level 2 (injury to customer)
__Level 3 (injury to employee)
__Level 4 (interior property damage)
__Level 5 (exterior property damage)

Closing Statement (if any) _________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ ____

Distribution List: Operations Manager, Security Manager, Corporate Attorney, Human Resources Manager, Individual Employees that were Involved.