Liability Report Form

Date of Occurrence:

Address of Occurrence:

Staff Name Reporting Accident:

Contact Phone Number:

Description of Occurrence:

Injuries

Name, Address, Phone:

Description of Injuries:

Medical Treatment:

Property Damage

Name, Address, Phone:

Description of Property Damage:

Witnesses:

Police Called (Department, Case Number):

Photos Obtained?

Additional Information:

Report within 24 hours