Cleaning Refusal Incident Report Form
Please complete this Cleaning Refusal Incident Report Form to document any refusal of cleaning services, including all relevant details of the incident.
Incident Location
*
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Reported By (Name)
*
Person Who Refused Cleaning (Name or Role)
*
Area or Room Involved
*
Type of Cleaning Requested
*
Reason for Refusal (if provided)
Refusal Method
*
Verbal
Written
Was a witness or supervisor involved?
*
Yes
No
Immediate Action Taken
Additional Notes
Submit Incident Report
Should be Empty: