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Cornerstone Incident Report #1
Use this form to report accidents, injuries, medical situations, criminal activities, traffic incidents, or b
ehavior incidents.
If possible, a report should be completed within 24 hours of the
event.
Name of person/witness filing report
Phone
Email
Name of person #1 involved in the incident
Email of person #1 involved in the incident
Phone number of person #1 involved in the incident
Name of person #2 involved in the incident
Email of person #2 involved in the incident
Phone number of person #2 involved in the incident
Date of Incident
Time of Incident
12:00 AM
12:05 AM
12:10 AM
12:15 AM
12:20 AM
12:25 AM
12:30 AM
12:35 AM
12:40 AM
12:45 AM
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11:30 PM
11:35 PM
11:40 PM
11:45 PM
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11:55 PM
Choose a time
Location of Incident
*
Clothing Bank
Community Kitchen
Community Center
The Lodge
New Hope House
Clairvaux House
Food Cupboard
Admin Offices
Other
If other, describe here
Describe the incident here
Were there any injuries during this incident?
*
Yes
No
If yes, describe the injuries here. Please include details of treatment provided, if EMS was called, and if/where the person was transported to the hospital.
Were there any witnesses to this incident?
*
Yes
No
I don't know
If yes, include thier name and contact information here
Were police notified of this incident?
*
No - Not applicable
Yes - police report was filed
Yes - police report was NOT filed
Thanks for submitting!
Submit
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