CCPLS Incident Report

updated January 2013

Please fill in all information as it applies.

Name of Staff Person Handling Incident:
Did this event result in personal injury or property damage?


Name of Person(s) Involved:
Sex: Male Female
Approximate Age:
Whom Notified:
Nature of Incident: Medical Vehicle Property Damage
Extreme Patron Behavior Other
Location of Incident:
Explanation & Comments:
(give detailed description)
Contributory Causes:
Call was made to:

Police Fire Department
Emergency/Ambulance Other

Time Call Made:
Time Party Called Arrived:
Responder's Name:
First-aid Given:
Other Solution:
Additional Comments:


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This form is sent to Administration who will forward it to appropriate staff members.

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