Driver Restroom Break Incident Report Form
Please complete this form to report and document any restroom break incidents involving a driver. Provide as much detail as possible to assist with follow-up and record-keeping.
Driver's Full Name
*
First Name
Last Name
Date of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Incident
*
Hour Minutes
AM
PM
AM/PM Option
Vehicle or Route Number
*
Location of Restroom Break
*
Duration of Restroom Break (minutes)
*
Was the break scheduled or unscheduled?
*
Scheduled
Unscheduled
Describe the Incident
*
Impact on Schedule or Operations
Person Reporting (Your Name)
*
First Name
Last Name
Submit Report
Should be Empty: