Incident Information Report
This form is for events or allegations of injury, illness, or property damage, including issues with staff members and board members.
Everyone who witnessed the incident should fill out a copy of this form and submit it to SLC Arts staff (if filled out after the incident, mail to: SLC Arts, PO Box 252, Potsdam NY 13676).
If completed on-line at <http://slcartscouncil.org/rent-facilities/>, Google Forms will automatically email you a copy of your responses after the form is submitted.
Email address
Date of incident
MM
/
DD
/
YYYY
Time of incident
Time
:
Where did the incident occur?
Your answer
List the names of everyone involved, their contact info (or physical description if no contact info available), and their roles in the incident (victim(s), witness(es), etc.):
Your answer
Fully describe what happened:
Your answer
Your name
Your answer
Today's date
MM
/
DD
/
YYYY
Your contact info
Your answer
Comments/other things we should know:
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms