GUARDIAN GUARDS
INCIDENT REPORT FORM
I. Person Reporting Incident/Accident
Emp. I.D. # or D.L. #
Date of Incident
Time of Incident
Date Reported
Time Reported
Who Else Notified
Site Name Where Incident Occurred
GGS/BGS Office Notified
yes
no
Supervisor Response
called
came to site
Supervisor Response (Appx:)
Type of Incident
Complete Appropriate #s
Injury
Change in Post Order (#s)
Theft
Auto Accident
Vandalism
Property Damage
Other:
Customer Complaint
II. Condition of Area
Dry
Wet: Posted
yes
no
Icy: Salted
yes
no
Other:
Well lighted area
Poorly lighted area
III. Weather Conditions
Appx. Temp:
Clear
Cloudy
Rain
Snow
Tornado Warning
Other:
IV. Where Did Incident Occur
In Building
In Parking Lot
On Grounds
In Vehicle
Other:
V. Police Called
yes
no
Police Response
yes
no
Dept:
Report Filed
yes
no
Fire Dept. Called
yes
no
Dept:
Ambulance Called
yes
no
Company:
VI. Other People
Agencies Contacted
1)
2)
3)
4)
5)
VII. Person Involved in Incident/Accident
Emp. I.D. # or D.L. #
D.O.B.
Telephone
Home Address:
City
State
Zip
First Aid Given
yes
no
Given By
Taken to Hospital
yes
no Which one:
Person Refused
yes
no
VIII. Witnesses
1) Name
D.L. # or I.D.#
Street Address
City
2) Name
D.L. # or I.D.#
Street Address
City
3) Name
D.L. # or I.D.#
Street Address
City
IX. Narrative:
Describe Incident in Your Words:
At approximately 3:15 P on 9-2-2009, writer was contacted via land line and advised of an injury accident in the north parking lot. At approximately 3:17 P writer responded to the north parking lot and found employee Steve Smith laying on the pavement in aisle 3 approximately 8 feet west of the second light pole from the west end. Mr. Smith was bleeding from the head and started that his left leg was broken, employee John. <p>Roberts was using a towel to stop the bleeding. MR. Smith stated that at approximately 3:10 P he was walking from this car to the employee entrance when a Black 4-door Ford LTD, unknown license number, failed to yield at the cross walk in aisle 3 and struck him on the left side, he further stated that the vehicle failed to stop after hitting him and exited the parking lot headed east on Main St, at a high rate of speed. At approximately 3:18 P Writer called 9-1-1 and requested police and EMS, at approximately 3:25 P Detroit F.D. EMS Unit #123 arrived on scene. <p>At approximately 3:30 P DPD Officer Bill White, badge #12345, Western District arrived to take the report. At approximately 3:40 P EMS transported Mr. Smith the Detroit Receiving Hospital. At approximately 3:55 P Officer White finished his investigation and left the scene. Writer then returned to security office to resume normal duties. Writer contacted Guardian dispatch and advised them of the incident. At approximately 4:30 P FOS Johnson arrived and was given copies of the incident report.