Incident Report - Stonebrook

Your name *

Email address *

Basic Information

Date, time, location, and type of incident.

Time of Incident *

Example: 1 PM

Location of Incident *

Auditorium

Balcony

Bathroom(s)

Cafe

Classroom(s)

Exterior

Foyer

Hallway(s)

Kitchen

Maintenance Closet(s)

Multipurpose Room

Nursery

Nursing Room

Office(s)

Parking Lot

Playground

Storage Room(s)

Upper Room

Outside of Stonebrook

Other

Type of Incident *

Assault / Misconduct

Close Call / Near Miss

Equipment / Property Damage

Fatality / Death

Injury / Illness

Lost / Missing Child

Other

People Involved

Record the names and contact information of the people involved in the incident, from the victims to witnesses

Were there any victim(s)? *

Were there any witness(es)? *

Were there any perpetrator(s)? *

Detailed Information

Describe as much detailed information of the incident.

Describe the Sequence of Events leading up to the Incident *

Description of Incident *

Were Unsafe Acts a contributing factor? *

Includes improper work, rule violations, horseplay, drug/alcohol use, etc.

Were Unsafe Conditions a contributing factor? *

Includes poor workstation, hazards, work areas, storage, equipment, conditions, etc.

Were Management System Deficiencies a contributing factor? *

Includes improper maintenance, supervision, planning, practices, safety rules, etc.

Any Other Contributing Factors *

Please describe all or any possible contributing factors that led to this incident.

Immediate Actions Taken *

Please describe any/all immediate actions that were taken after the incident occurred (if any).

Recommendations *

Please include any suggestions or recommendations to improve safety or prevent similar incidents from occurring in the future.

Evidence of Incident

Please include any supporting evidence such as photos or videos of the incident. Also include any witness statements provided.

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Add up to 5 files. Maximum file size 10 MB.

Corrective Actions / Prevention

Were any Corrective Actions made or will be taken to prevent a recurrence? *

E-Signature

Please sign off on this report.

The information above is freely provided and is true to the best of my knowledge. This constitutes a digital signature. *

Check all that apply:

I am a mandatory reporter.

I choose to remain anonymous regarding this incident.

I have reported or intend to report this incident to law enforcement.