Information
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Be sure to fill in the report title and guard name
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Date/Time report is started
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Report Title. (***required***)
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Reporting guard name (***required***)
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Document No.
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Make sure to answer ALL yes/no questions and fill in all blank spaces, even if it doesn't seem to apply to the situation.
Overview
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Do we know when the event occurred?
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Date/Time of the event
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Estimated time between
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And...
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Detailed description of the scene (guard's observations)
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Photos
Personnel involved/present
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If a person was involved/present at the event, click here to add-->
If more than one person, click the button multiple times.
Person
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Person is...
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Employee's name
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Badge or ID number
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How was employee involved?
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Explain employee' involvement
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Department
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Supervisor
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Employee's statement
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Was a drug/alcohol test required?
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Who administered the drug screen?
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Enter location
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Time of specimen collection
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Who administered the alcohol screen?
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Enter location
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Time of rinse
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Time of swab (should be at least 15 min. after rinse)
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Was the employee injured?
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Nature of injury
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If person refused treatment, check the box -->
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Have employee sign refusal of treatment form.
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Treatment location
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Give details
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Who transported the injured person?
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Time Birmingham FD entered plant
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Time Birmingham FD left plant
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Other notes
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Explain
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Person's name
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ID or driver's license number
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Description of individual (If ID is not known)
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How was person involved?
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Explain person's involvement
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Company
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Contact info
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Person's statement
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Was the person injured?
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Nature of injury
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If person refused treatment, check the box -->
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Signature
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Treatment location
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Give details
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Who transported the injured person?
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Time Birmingham FD entered plant
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Time Birmingham FD left plant
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Other notes
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Explain
Damage
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Were any company-owned passenger vehicles involved? <br>(Truck, car, bus)
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Click the button to add company-owned vehicle -->
If more than one is involved, click the button multiple times
Company-owned vehicle
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Vehicle type
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Unit number
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Who was driving?
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List any passengers
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Department the vehicle belongs to
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Close-up of damage
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M-2054Q
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Was any company-owned equipment involved?<br>(Forklift, crane, machinery, golf cart, etc)<br>
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Click the button to add equipment -->
If more than one was involved, click the button multiple times
Equipment
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Equipment type
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Unit number
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Who was operating the equipment?
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Department that the equipment belongs to
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Close-up of damage
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Was any NON company owned vehicles or equipment involved? <br>(Vehicles, trailers, generators, etc. belonging to contractors or visitors)
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Click the button to add non Acipco equipment -->
If more than one is involved, click the button multiple times
outside equipment
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Vehicle or equipment type
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Unit or tag number
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Driver or operator name
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List any passengers
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Who equipment belongs to
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Owner's address and contact info
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Insurance company and policy number (If applicable)
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Close-up of damage
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M-2054Q
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Were any stationary structures damaged?<br>(Buildings, runs, tracks, fences, etc)
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Specific location of the structural damage
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Department
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Close-up of damage
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Was any product(s) damaged?<br>(Pipes, fittings, valves, etc.)
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Click the button to enter product that was damaged -->
(If more than one piece was damaged, enter new lines for each size or class)
Product
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Type and class (ex. 32" FST class 350)
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Number of pieces damaged
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Number of pieces scrapped
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Serial or run number (if applicable)
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Close-up of damage
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Notes
Fire
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Was there a fire involved?
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Specific location of the fire
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Damage
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Person who reported the fire
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Weather/environmental conditions
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Time guards were notified
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Time guards arrived
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Name of guards who responded
- Tori Perry
- Mike Whaley
- Mark Sanders
- Steve Royster
- Alan Works
- Larry McKay
- Demetrius Gordon
- Bobby Kizziah
- Tommy Wilson
- Joe Ryan
- Marlon Fowler
- Eddie Lancaster
- Deborah Russell
- James Washington
- Marty Rios
- Steve Hallmark
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Was the fire department called?
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Time fire department entered plant
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Time fire department left plant
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Additional notes
Theft of property
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Was there a theft involved?
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Department
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Approximate date/time theft was discovered
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Reporting employee name
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Badge number
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Employee's statement
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Supervisor
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Click the button to add item stolen -->
If more than one item, click the button multiple times
Item
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Item description
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Estimated value
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Serial number (if applicable)
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Approximate size and weight
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Who owned the item?
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Owner
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Badge number
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Contact info
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Owner
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Contact info
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Has any item like this been stolen in the recent past?
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Approximate date of previous theft
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Was the item under lock?
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Was the lock broken?
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Were any tools used in the theft?
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Explain
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Photos of tools
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Was there any damage inflicted during the theft?
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Explain
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Photos of damage
Trespassing
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Was a trespasser involved?
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Trespasser's name
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Address
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Apparent Age
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Physical description
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Photo of trespasser
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Trespasser's statement
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Search of trespasser: Request trespasser empty all pockets, bags, sacks, et. Describe any stolen items or items of interest below. If trespasser refuses, notate below.
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Photos of contents
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If there was more than one trespasser, click the button -->
Trespasser
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Trespasser's name
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Address
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Apparent Age
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Physical description
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Photo of trespasser
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Trespasser's statement
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Search of trespasser: Request trespasser empty all pockets, bags, sacks, et. Describe any stolen items or items of interest below. If trespasser refuses, notate below.
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Photos of contents
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Were the police called for assistance?
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Officer name
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Case number
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Notes
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Description of scene: Include entry point, where apprehended, description of stolen items, etc.
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Photos of scene
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M-926Q
Additional information
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Signature of reporting guard
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Names of additional guards at the scene
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Notes
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Other images
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Sergeant signature
