Incident Report Form

SECTION A: INCIDENT INFORMATION

Incident Report #: Date of Report:

Date of Incident: Time of Incident:

Venue:

City:

Exact Location: (e.g., stage left, main entrance, dressing room, etc.)

SECTION B: TYPE OF INCIDENT

Severity Level:

MINOR
No injury/Minor property damage

MODERATE
Minor injury/Moderate damage

SERIOUS
Major injury/Significant damage

SECTION C: INVOLVED PARTIES

Person(s) Involved (Primary):

Name	Role	Phone	Email
	☐ Patron ☐ Staff ☐ Artist ☐ Vendor ☐ Other
	☐ Patron ☐ Staff ☐ Artist ☐ Vendor ☐ Other

Witness(es):

Name	Role	Phone	Email

SECTION D: INCIDENT DESCRIPTION

Describe in detail what happened:

What was the person doing at the time of the incident?

How did the incident occur?

What was the immediate response?

SECTION E: INJURY DETAILS (Complete if injury occurred)

Nature of Injury:

Body Part Affected:

Cause of Injury:

Treatment Provided:

First Aid On-Site EMT/Paramedics Called Referred to Hospital Declined Treatment No Treatment Needed

Treated By:

Hospital/Medical Facility:

SECTION F: PROPERTY DAMAGE (Complete if damage occurred)

Property Owner:

Description of Property:

Estimated Value:

Description of Damage:

SECTION G: RESPONSE & FOLLOW-UP

Emergency Services Contacted:

Police Fire Ambulance None Required

Police Report #:

Notifications Made To:

Name	Position	Time Notified	Method
			☐ Phone ☐ In-Person ☐ Email
			☐ Phone ☐ In-Person ☐ Email

Corrective Actions Taken / Recommended:

Follow-Up Required?

Yes (explain below) No

SECTION H: ATTACHMENTS

Documents Attached:

Photos Video Witness Statements Medical Report Police Report Insurance Claim Other: ________

SIGNATURES

Report Completed By:

Signature / Printed Name / Date

Position: _________________

Reviewed By Supervisor:

Signature / Printed Name / Date

Position: _________________