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JCC SoCo Incident Report
Person Filing Report
Full Name
Title/Role
Date
The Incident
Type of Incident
Date and time of when the incident occurred
Location of incident (be specific as possible)
What was happening at the time of the incident?
Describe Incident in Detail
Attach any photo evidence of damages or injury (where appropriate)
Upload File(s)
Affected Individuals
Were there people involved in the incident?
Yes
No (skip section below)
Person One
Name
Title/Role
How long have they been in the position?
Contact Phone Number
Person Two
Name
Title/Role
How long have they been in the position?
Contact Phone Number
Witnesses & Statements
Witness 1
Name
Witness' Contact Information
Statement
Witness 2
Name
Witness' Contact Information
Statement
Police / Medical Services
Were the police notified?
Yes
No
If yes, was a report filed?
Yes
No
Was medical treatment provided?
Yes
No
Refused
Actions Taken
What actions will be taken to eliminate future repeats of the incident?
Submit
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