Date of the Incident: <> Activation Level: ( 1 2 3 4)
(Circle One)
Manager in Charge of Incident: <Individual on Call at the Time>
Description of the Event:__________________________________________________________________________________________
__________________________________________________________________________________________________________
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Who Reported the Incident? __________________________________________________________________________
Was Anyone Injured?_______________________________________________________________________________
Nature of the Injury.______________________________________________________________________________
______________________________________________________________________________________________
Was There Property Damage?_________________________________________________________________________
Nature of the Damage._____________________________________________________________________________
_____________________________________________________________________________________________
Was There a Response by Outside Resources (e.g., Fire Department). ______________________________________________
Description of the Response. _________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Follow-Up Steps Taken. ____________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Person Filing This Report._________________