Incident and Building Reporting
What type of incident?
Please Select
Safety & Security
Personal Injury
Medical Emergency
Fire/Smoke
Security Concern
Violence/Fight
Threat or Intimidation
Theft
Vandalism
Suspicious Person
Police Response
Building & Facilities
Building Damage
Water Leak/Flood
Electrical Issue
HVAC/Heating/Cooling
Plumbing Issue
Pest Issue
Equipment Failure
Utility Outage (Power/Water/Internet)
Cleaning/Sanitation Concern
Hazard (Slip, Trip, Fall)
Staff & Personnel
Staff Conflict
Employee Conduct
Attendance/Tardiness
Performance Concern
Policy Violation
Harassment/Discrimination
Confidentiality Breach
Program Participants
Participant Injury
Participant Behavior
Mental Health Crisis
Substance Use/Overdose
Child Safety Concern
Parent/Guardian Issue
Participant Dispute
Programs & Operations
Food Safety Issue
Meal/Service Disruption
Vehicle/Transportation Incident
Volunteer Issue
Partner Agency Issue
Technology/Computer Issue
Inventory Loss
Financial/Cash Handling Issue
Community
Community Complaint
Neighbor Concern
Positive Community Interaction
Outreach/Event Issue
Media Inquiry
Other
Near Miss (Could have caused injury or damage)
Positive Incident/Recognition
Other
Person Reporting
First Name
Last Name
Supervisor's Name
First Name
Last Name
Date of incident/Accident
-
Month
-
Day
Year
Date Picker Icon
Time of incident/Accident
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Severity
Please Select
Informational
Low
Moderate
High
Critical
Location
Please Select
1st Fl - Cafeteria
1st Fl - Kitchen
1st Fl - Hallway
1st Fl - Daycare
1st Fl - Packing
1st Fl - Social Services
1st Fl - Front Office
1st Fl - Back Office
2nd Fl - Safe Exits
2nd Fl - Classroom
2nd Fl - Hallway
2nd Fl - FF4Fathers
2nd Fl - Studio
2nd Fl - Hub
2nd Fl - Clothing Rooms
2nd Fl - Difference makers
2nd Fl - Bike Room
2nd Fl - Large Classroom
Front Stairwell
Ashton Stairwell
Smallwood Stairwell
Front of Building
Side of Building
Back of Building
Dumpster Area
Van
Parking Lot
Street
Personal Injury
Please Select
N/A
Ankle
Arm
Foot
Hand
Head
Groin
Knee
Neck
Shoulder
Back
Chest
Knee
Other
Property Loss or Damage
Please Select
Yes
No
Action Taken
Please Select
First Aid Provided
911 Called
Police Called
Fire Department Responded
Maintenance Notified
Supervisor Notified
Participant Sent Home
Board Notified
Incident Resolved
Follow-Up Required
People Involved
Staff
Volunteer
Youth Participant
Community Member
Visitor
Vendor
Partner Organization
Unknown
Witnesses
Please Select
Yes
No
Witness/Witnesses Names
Area Conditions (Check all that apply):
Dry
Wet
Cluttered
Poor Lighting
Obstructed Walkway
Uneven Surface
Construction/Maintenance
Hot
Cold
Noisy
Crowded
Smoke/Odor Present
Electrical Hazard
Water Leak
Other
Task was being performed at the time of the incident/Accident?
Please Select
Serving Client
Cleaning
Cooking
Delivery
Popup Market
Event
Unloading
Loading
Picking
Packing
Inventory
Put away
Driving
Administration
Computer work
Description
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Recommendations to Prevent Future Incidents
Success Story / Positive Outcome (Mitigation, Crisis successfully resolved, ect)
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