Incident Report Form (Page 2 of 2) in pdf

Incident Report Form Page 2

Page 2

Name: (injured party) __________________________________ Date: ______________________

Was a vehicle(s) involved ______ No ______Yes – Make & Model: _______________________

Year: ________

Where was vehicle parked? ___________________________________

Medical treatment required: _______ No ________Yes - Medical Facility : __________________

Did emergency officials respond? _______ No ________Yes

Is this incident being investigated by authorities ? _______ No ________ Yes

Officer’s name/affiliation:_________________________ Case#: ___________________________

Did anyone involved in this incident threaten a lawsuit ? ______ NO ______ Yes - Provide Details:

Witness(es):

Name: ___________________________ Phone #: (______)_____________________

Current status of situation / outcome of the incident :

Person completing report: ____________________________________Date: __________________

Print name:_______________________________________________________________________

Incident Report Form Page 2