SKA Guest Incident Report

• Date of Incident

  Date

• Prepared by

• Signature

  Sign

• Incident Number

• Reported by:

• Type of incident:

• Location of Incident:

• Guest Name

• Guest Contact Number

• Guest Date of Birth

  Date

• Guest Address

• Guest City

• Guest Province/State

• Guest Postal/Zip Code

• Guest Email

• Details of Incident:

• Guest Signature

  Sign

• Was Medical Attention Required

  Yes

  No

  N/A

• Was an ambulance called to assist the guest

  Yes

  No

  N/A

• Was First Aid Given

  Yes

  No

  N/A

• What type of first aid was given

Witness Statement #1

• Witness

• Phone

• Email

• Witness Statement

• Witness Signature

  Sign

Witness Statement #2

• Witness

• Phone

• Email

• Witness Statement

• Witness Signature

  Sign

Reporting Staff Witness

• Staff Who Witnessed Incident:

• Phone

• Email

• Staff Statement

• Staff Signature

  Sign

Colleague/Leader Follow-up with guest Information:

• Follow Up Date:

  Date

• Colleague/Leader Name

• Details: