Time of the incident                                                                                           Date

Where did the incident occur?

Name(s) of those involved.

Give your account of the event.  Include what you were doing at the time.

 

 

Name(s) of those injured.

 

If you assisted those that were injured, what did you do?

 

Was there anything that you might have seen or heard that may be relevant to the incident?

 

What should be done to prevent a recurrence of the incident?

 

9/04