Property Damage Report Form
Incident Date & Time
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Personal Injury
Employee/volunteer
Non-Employee
N/A
Other
Specific site of incident
Department
Activity/Program
Description of Incident
Describe the incident, how did it occur, who/what was involved, etc. Provide only factual accounts and/or observations.
Property Damage
Please select if there is any property damages
No damages
Equipment
Structural (i.e. building, windows)
Furnishings (i.e. chair, mirror, file cabinet)
Vessel
Vehicle
Other
Please give details
Witnesses
Witnesses
Remarks & Follow Up
Special Remarks (If Applicable)
Provide additional information regarding the injury/illness that youbelieve is important.
Follow Up
This section is to be completed by the Supervisor and/or Director/Associate/AssistantDirector.
Prepared By
Name
First Name
Last Name
Title
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: