HTML Preview Damage Incident page number 1.

Incident/Property Damage First Report Form
Reported by Dept. Date
Date of Incident Time of Incident am pm
Location of Incident
Was Police Department Notified yes no Fire Department/EMS yes no
Please provide a brief description of the type of damage:
Injury to Person
Damage to Property
Other (describe)
Vehicle (see other side)
Name of Party Phone
Address (include complete address, with street address, city, state and zip)
Briefly Describe What Happened:
Cause of damage/injury
Contributing Factors
Is injured party a Town employee? Has Supervisor been notified?
Did the injured party refuse medical attention? yes no
Name Address Phone
Name Address Phone
Name Address Phone
Follow up Action
Date Comments
Incident/Property Damage Report Form Updated April 7, 2015

The great accomplishments of man have resulted from the transmission of ideas of enthusiasm. | Thomas J. Watson