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Incident Report Form
Use this form to report accidents, injuries, medical situations, or behavior incidents. (Incidents involving a crime or violence should be reported to the Police as well.) The report should be completed within 24 hours of the event.
INFORMATION ABOUT PERSON INVOLVED IN THE INCIDENT
Relation

Employee Guest Others
Name

First Name
Last Name
Suffix
Birthdate
Month - Day - Year

Home Address

Street Address
Street Address 2
City	Region
Postal Code	Country

Phone
Area CodeHome
.
Area CodeCell
.
Area CodeWork
Email
INFORMATION ABOUT THE INCIDENT
Date & Time of incident
Month / Day / Year
Hour : Minutes
Location of incident
Description of incident
(What happened, how it happened, factors leading to the event, etc.) Be as specific as possible
Upload Images
Filename
Size
Process
Status
Add Files
Was the individual injured?
If so, describe the injury (laceration, sprain, etc.), the part of body injured, and any other information known about the resulting injury(ies).
Was medical treatment provided?

YES NO REFUSED
If yes, where was treatment provided?

ON SITE FIRST AID EMT / FIRST RESPONDERS Others
Describe the treatment provided.
Include who provided treatment, what was needed, etc...
Were there any witnesses to the incident? (If yes, list below and have them fill out an incident witness report)

YES NO
List witnesses below with full name & contact info
Post-Incident Evaluation
Where did the individual go after the incident?
Stayed on site? Went home? Which hospital?
What was done immediately to address the hazard(s) that caused the incident?
Examples: Cleaned up spill / Wet floor sign. Closed off area. Marked equipment out of order.
Suggest corrective measures to prevent future incidents
Should procedures or policies be removed, added, or modified? Fix equipment? Signs? Lights? Etc...
Reporter Information
Name of person filing report

First Name
Last Name
Suffix
Phone
Area CodePrimary Phone Number
Phone
Area CodeSecondary Phone Number
Email

(636) 227-1469
mail@westcountylanes.com
15727 Manchester Rd.
Ellisville, MO 63011

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