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.______________________________________________________________________________

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Was There Property Damage?_________________________________________________________________________

Nature of the Damage._____________________________________________________________________________

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Was There a Response by Outside Resources (e.g., Fire Department). ______________________________________________

Description of the Response. _________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Follow-Up Steps Taken. ____________________________________________________________________________

_____________________________________________________________________________________________

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Person Filing This Report._________________