MOD LMPBR Incident Report V2017

• Period

  Morning

  Afternoon

  Night

• Name

• Department/Position

• Date

  Date

Detail

• Incident Name

• Prepared By

• Date/Time Prepared

  Date

• Cell

Incident Event Log

• Event Log

Incident

• Time

  Date

• Event

• INCIDENT REPORT
  General (e.g. eviction of guest,arrest by local authorities, guest struck in elevator, fire alarm, etc.)

General incident form

• Hotel code

• Incident No:

• Claim Handlind Instructions

  Select Information only Establish Claim

  • Information only
  • Establish Claim

• Hotel

• Name: Mr./Ms.Mrs.

• Home phone:

• Work phone:

• Address:(Street,City,State/Prov,Zip/Postal Code)

• Type

  Rgsistered Guest

  Patron

  Other

• Room number

• Birthdate/Approx Age

• Location of incident

• Occured on :

  Occured

  Between

• Occured on:

  Date

• Occured on:

  Date

• Finish on:

  Date

• Reported on:

  Date

• Type of incident

• Reported to: (name/title)

Detail of incident: Fact only (who, what, when, where, and how according to claimant and other witnesses)

• Witness(es): Name, address, home & work phone number

Person

• Police/Fire Department Information

• Department Name:

• Notification Date/Time

  Date

• Office's Name:

• Badge Number:

• Case Number:

• Report Prepared by:

  Sign

• Date & Time:

  Date

• Report reviewed by:

  Sign

• Date & Time:

  Date

• Details of Incident, continued:

• Details of Incident, continued:

• Any Additional Document Nessary?(Example:pictures, diagrams, damaged, equipment, folio, registration card, bar bill, room access information, etc.)

  Yes

  No

• Location of Additional Documentation or Evidence:

• INCIDENT REPORT
  Guest/Patron/Third-party
  Loss/Damage to property or injury/illnessi

Guest/Patron/Third-party incident report

• Hotel code 1848

• Incident No:

• Claim Handlind Instructions

  Select Information only Establish Claim

  • Information only
  • Establish Claim

• Hotel: Le meridien phuket beach resort

• Name:

• Home phone:

• Work phone:

• Address:(Street,City,State/Prov,Zip/Postal Code)

• Type

  Rgsistered Guest

  Patron

  Other

• Room Number

• Check in date:

  Date

• Check out date:

  Date

• Birthdate/Approx Age

• Location of incident

• Occured on :

  Occured

  Between

• Occured on:

  Date

• Occured on:

  Date

• Finish on:

  Date

• Reported on:

  Date

• Reported to: (name/title)

• Type of incident

  Select Loss of property Damage to property Injury/illness

  • Loss of property
  • Damage to property
  • Injury/illness

• If loss /damage to property , describe item(s)

• Guest estimate of loss/damage:$

• If injury, nature of injury:

• Visible injuries:

• Claimed unjuries / illness

• Part(s) of body affected: (Be specific)

• First Aid

  Yes

  No

• Administered

  Yes

  No

• If administered, type of first aid:

• Administered by: (name, title)

• Transported to doctor/hospital:

  Yes

  No

• If so, transported by:

• Transported to:

Detail of incident: Fact only (who, what, when, where, and how according to claimant and other witnesses) Describe clothing, shoes, glasses worn, etc.

• Case Manager:

• Witness(es): Name, address, home & work phone number

Person

• Police/Fire Department Information

• Department Name:

• Notification Date/Time

  Date

• Office's Name:

• Case Number:

• Report Prepared by:

  Sign

• Date & Time:

  Date

• Report reviewed by:

  Sign

• Date & Time:

  Date

• Details of Incident, continued:

• Details of Incident, continued:

• Any Additional Document Nessary?(Example:pictures, diagrams, damaged, equipment, folio, registration card, bar bill, room access information, etc.)

  Yes

  No

• Location of Additional Documentation or Evidence:

• Supervisor's accident report
  Associate
  injury/illness

Supervisor's accident report

• Hotel/Dept.code

• Incident No:

• Claim Handlind Instructions

  Select Information only Establish Claim

  • Information only
  • Establish Claim

• Hotel: Le meridien phuket beach resort

• Associate's Name:

• Administrative use only: osha reporting Time loss:

  Select Yes No Recordable Non-Recordable

  • Yes
  • No
  • Recordable
  • Non-Recordable

• Address:(Street,City,State/Prov,Zip/Postal Code)

• Home phone:

• Social Security Number

• Associate ID:

• Sex:

  Male

  Female

• Birthdate:

  Date

• Department

• Position:

• Hire Date:

• Schedule Shift:

  Morning

  Afternoon

  Night

• Rate of Pay:

• Scheduled Days off:

• Location of incident

• Occured on :

  Occured

  Between

• Occured on:

  Date

• Occured on:

  Date

• Finish on:

  Date

• Reported on:

  Date

• Nature of injury:

• Visible injuries:

• Claimed unjuries / illness

• Reported to: (name/title)

• Part(s) of body affected: (Be specific)

• First Aid

  Yes

  No

• Administered

  Yes

  No

• If administered, type of first aid:

• Administered by: (name, title)

• Transported to doctor/hospital:

  Yes

  No

• If so, transported by:

• Transported to:

Detail of incident: Fact only (who, what, when, where, and how according to claimant and other witnesses) Describe clothing, shoes, glasses worn, etc.

• Witness(es): Name, address, home & work phone number

Person

• Signature of Associate:

  Sign

• Date & Time:

  Date

• Signature of Supervisor:

  Sign

• Date & Time:

  Date

• Report Prepared by:

  Sign

• Date & Time:

  Date

• Details of Incident, continued:

• Details of Incident, continued:

• Any Additional Document Nessary?(Example:pictures, diagrams, damaged, equipment, folio, registration card, bar bill, room access information, etc.)

  Yes

  No

• Location of Additional Documentation or Evidence:

• INCIDENT REPORT
  Hotel property loss or damage

Hotel property loss or damage

• Hotel code

• Incident No:

• Claim Handlind Instructions

  Select Information only Establish Claim

  • Information only
  • Establish Claim

• Name of Hotel:

• Nature of Loss/Damage

• Location of incident:

• Description of damage:

• Occured on :

  Occured

  Between

• Occured on:

  Date

• Occured on:

  Date

• Finish on:

  Date

• Reported on:

  Date

• Estimate of loss/damage:

• Reported to: (name/title)

• NOTE: if loss/damage exceeds propety deductible (refer to the Insurance Policy Disgest), report the loss to the Coporate Risk Management Department immediately

Detail of incident: Fact only (who, what, when, where, and how )

• Anticipated loss of business?

  Yes

  No

• If so, estimate extent, and for how long.

• Step to repair the damage and prevent futher loss.

• Dose loss/damage affect a third party (e.g. Tenant?)

  Yes

  No

• If so, who, and to what extent.

• Witness(es): Name, address, home & work phone number

Person

• Police/Fire Department Information

• Department Name:

• Notification Date/Time

  Date

• Office's Name:

• Case Number:

• Any Additional Document Nessary?(Example:pictures, diagrams, damaged, equipment, folio, registration card, bar bill, room access information, etc.)

  Yes

  No

• Location of Additional Documentation or Evidence:

• Report Prepared by:

  Sign

• Date & Time:

  Date

• Report reviewed by:

  Sign

• Date & Time:

  Date

• Details of Incident, continued:

• Details of Incident, continued:

• Any Additional Document Nessary?(Example:pictures, diagrams, damaged, equipment, folio, registration card, bar bill, room access information, etc.)

  Yes

  No

• Location of Additional Documentation or Evidence: