Date of Incident: _____/_____/________ Time of Incident: ________ AM PM
Library: Open Closed
Print full name of affected individual (if applicable): ____________________________________________
Affected individual: Staff Volunteer Patron Other ______________________
Affected individual: Adult Child ___Parent present ___Parent not present
Parent/Guardian Name & Phone: __________________________________________ Parent contacted
Home Address: __________________________________________________________________________
Phone Number: (____) ______-___________ Email Address: _________________________________
- Activity before incident: _________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________
- Location of incident and condition of area: __________________________________________________
________________________________________________________________________________________________________________________________________________________________________
- What activity was the individual doing? ____________________________________________________
________________________________________________________________________________________________________________________________________________________________________
Type of incident: Personal Injury (if no property damage Go to #6)
Personal Property Damage (Go to #5) Library Property Damage (Go to #5)
- Please briefly describe incident of property damage: _________________________________________
________________________________________________________________________________________________________________________________________________________________________
Estimated value/cost of damaged items _______________________
- If personal injury, describe nature of injury reported and how it occurred (Ex: Small puncture to tip of first finger right hand while removing staple from paper): _________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Medical Aid Rendered: Yes (describe below) No- why not? ___ Refused or ___ None required
First Aid Provided: ____________________________________________________________
______________________________________________________________________________
Emergency Personnel Called: Yes Time called: ______________ No
Transported to: Urgent Care Hospital Home Other
Transported via: Personal Vehicle Rescue Squad Other:__________________
Affected individual released to: Self Parent Other: ________________________
Witness(es) present at time of incident: Yes No
- Provide full name, address and phone number of each witness:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- Witness Statements:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
If more room needed, please use additional paper.
- Name of Person Completing Report: ____________________________________________________
Position (if applicable): _____________________________________
Date form completed: ________________________________________
Adopted by the Board of Trustees on: September 3, 2025