This document is an example of an incident report template. This document is a blank
form, and should be filled out by the person reporting the incident. This form includes
sections to be filled out, such as what was taking place when the incident occurred; who
witnessed the incident, and a description of who the perpetrator is. This document in its
draft form contains numerous of the standard clauses commonly used in these types of
forms; however, additional language can easily be added. This document can be used
by small businesses and is useful to document incidents that occur within the company.
INCIDENT REPORT
TEMPLATE
(Insert Year)
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Introduction:
Complete a separate form for each incident, within three (3) days of the incident occurring.
Remember that failure to report an incident could result in someone else being put at risk in the
future.
This form should be used for each occasion of:
Aggressive behavior
Verbal abuse
Destruction of equipment or property (or threats of)
Physical assault (or threats of)
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Name of person completing the form:
Last Name: _____________________________ First Name: __________________________
Position title: ___________________________
Date of incident: _________________________
Time: _______________ [Circle one] AM / PM
Location of incident:
_____________________________________
_____________________________________
_____________________________________
What was taking place when the incident occurred?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
________________________________________
Other persons present at the time:
Last Name 1: ____________________________ First Name 1:_________________________
Last Name 2: ____________________________ First Name 2:_________________________
Last Name 3: ____________________________ First Name 3:_________________________
Last Name 4: ____________________________ First Name 4:_________________________
Name of perpetrator(s) if known, or description if unknown:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
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__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________________
Was the perpetrator(s):
Y N
A young person who is known to the service (i.e. client)
A young person unknown to the service
A relative of a young person
A friend of a young person
A partner or ex-pa