Incident Report Form

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Incident Report Form
Date of incident
Time of incident
Location
Type of Problem
Severity
o Accident
o Building malfunction
o Minor
o Drug, alcohol or
o Fire
o Major
o Unattended children
psychiatric
o Difficult to assess
o Patron disturbance
o Serious medical/death
o Theft/Robbery
o Injury
Action Taken
o Bomb threat
o Policy violation
o Explosion
o Sexual harassment
o Ambulance called
o Tornado
o Verbal abuse
o Police called
o Other
o Vandalism
o Cleared library
o Utility Co. called
o Fire Dept. called
o Library Admin. Called
o Other (handled within library)
Person notified:__________________________________________
If the incident involved a patron(s) or staff member, please list name(s) and address(es). If minor, also give parent’s
name and address.
Name of patron(s) involved:
Phone Number:
_________________________________________________________________
__________________________
Address:
_________________________________________________________________
Brief, but precise, description of the incident:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Name of employee reporting incident:___________________________________________________
Employee’s signature:_________________________________________________________
Director’s signature:__________________________________________________________
Date ___/___/______
Time ______:_______
Date Board notified ___/___/_____
Approved by Library Board of Trustees on January 12, 2017.

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