Incident Report Form

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INCIDENT REPORT
Property Name: _______________________________________________
Property Location Address: _____________________________________
Name of Person Injured: _____________________________________
Address – Home: ______________________________________________
Street
City
State
Zip
Business: _______________________________________________
Street
City
State
Zip
Telephone # : Home ( ___ ) ___________________
Business #: ( ___ ) ____________________
Property Contact: _________________________________
Date of incident: _______________________ Time of incident: _________________
A.M. or P.M.
Month
Date
Year
Date incident reported: ___________________ Time incident reported: ____________
A.M. or P.M
Month
Date
Year
Person injured or affected: – ____Guest or ____ Non- guest or ____ Hotel employee
If Guest: Check-in date: __________ Time:__________ Room: __________
If non-guest : purpose of hotel visit : ______________________________________
Thorough description (include: incident, nature of injury, material damages, outcome, etc. )
Location of incident:

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