Free Incident Report Template 58Free Incident Report Template 58Free Incident Report Template 58
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EMPATHY Program Incident Report
* Complete a separate form for each incident, within 3 days of the incident occurring.
* Remember that failure to report an incident could result in someone else being
put at risk in the future.
This form should be used for each occasion of
 Aggressive behaviour
 Verbal abuse
 Destruction of equipment or property (or threats of)
 Physical assault (or threats of)
Name of person completing the form: ______________________________________
Position title:__________________________________________________________

Date of incident : _________________
Time: _______________ am/pm
Location of incident: _____________________________________
What was taking place when the incident occurred? __________________________
____________________________________________________________________
Other persons present at the time:________________________________________
Name of perpetrator if known, or description if unknown: ______________________
_______________________