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:__________________________________________________________________________ _______________________________________________________________________________________
Who Reported the Incident? __________________________________________________________________________
Was Anyone Injured? _________________________________________________________________________
Nature of the Injury. _____________________________________________________________ _______________________________________________________________________________________
Was There Property Damage? __________________________________________________________________
Nature of the Damage.______________________________________________________________ _______________________________________________________________________________________
Was There a Response by Outside Resources (e.g., Fire Department)? ______________________________________________
Description of the Response. _________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________
Follow-Up Steps Taken. ____________________________________________________________________________ _______________________________________________________________________________________
Person Filing This Report._________________