Firehouse Incident Report Form
Please complete this form to report an incident that has occurred at the Firehouse. This information will be received by Erin and Derrick Roos, owners of the Firehouse Swing Dance.
Date of Incident
MM
/
DD
/
YYYY
Time of Incident
Time
:
Location of Incident
(i.e. Main Ballroom, blues room, library etc)
Your answer
Person(s) Involved & Contact Info
Please include First/Last Names, Phone numbers, Email, and involvement in the Firehouse (i.e. staff, attendee etc)
Your answer
Witnesses- Names, Contact Info, Involvement
Your answer
Incident Type
Incident Description
Your answer
Action Taken
Your answer
Was anyone injured as a result of this incident?
Staff Notified
Your answer
Submitter Information
First/Last Name, Phone Number, Email, Involvement in Firehouse
Your answer
Submit
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