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
Destruction of equipment or property (or threats of)
Physical assault (or threats of)
Name of person completing the form: ______________________________________
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: ______________________