Employee’s Incident Report – Elite Parking Management Services

Name

First Last

Date

Time of this report

: HH

MM

Job tittle

Date of Incident

Time started working

: HH

MM

Time of this Incident

: HH

MM

Location of Incident

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Area of worksite

In your words, describe fully how the incident happened, including what specific activity you were doing just before and when the incident took place, as well as the chain of events leading up to the incident:

Was there property damage

If yes, what property/equipment was damaged

Describe the damage

Post Damges

Can you think of anything you could have done differently or how possibly we can prevent this incident from happening again?

Were you working where other co-workers were nearby or present when the incident happened?

Co-workers on site

First Last

Co-workers on site

First Last

Who did you report this incident to?

First Last

Name of your supervisor

First Last

When did you first report this incident to your supervisor? Date:

Time

: HH

MM

I certify that these are true and accurate statements of my incident/injury that occurred on

Electronic signature

First Last