client or employee incident report

Location of Incident

Please select location where incident occurred

Date

Please indicate the date of incident

YYYY

Time

Please indicate the estimated time of incident

Hour

Minute

Second

Guest or Team Member Name involved in Incident

First Name

Last Name

Guest or Team Member Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Guest or Team Member Email Address

Best Follow Up Phone Number

(###)

###

####

Area where incident occurred

Please describe the area where the incident occurred

Medical Attention Required

Please indicate if medical assistance was required or requested at time of incident (i.e. Ambulance, physician, sent to Urgent Care, etc.

Yes

Name of Physician

Indicate name of physician involved if applicable

Physician Phone Number

(###)

###

####

Description of Incident

Staff Members on Duty at Time of Incident

Please list all staff members who were present at time of incident

Property Damage

Please indicate if any property was damaged in incident at Float Sixty or personal property