Mandatory Reporting Protocol: Incidents that must be reported and documented include all injuries or property damage occurring at the property. Report facts, not opinions. Attach photos or documentation when available. Within 24 hours of an incident, please provide a signed report to Josh Page, Director of Operations (Josh@riseselect.com). If an incident involves employees, please complete relevant First Report of Injury documentation using your state-specific form and provide a copy to Josh@riseselect.com and HR@riseselect.com.
General Information
Reporter & Incident Overview
Please provide complete factual details regarding the incident report details:
| Reporter Information | |
|---|---|
| Prepared By | __________________________________________________ |
| Title | __________________________________________________ |
| Property | __________________________________________________ |
| Address | __________________________________________________ |
| Phone | __________________________________________________ |
| Date Reported | __________________________________________________ |
| Incident Time & Weather Details | |
|---|---|
| Date of Accident/Incident | __________________________________________________ |
| Time | __________________________________________________ |
| Weather Conditions | __________________________________________________ |
| Person Reporting Incident (Name / Contact) | __________________________________________________ |
| Description of Accident / Incident | __________________________________________________ |
| Witnesses | __________________________________________________ |
Property Damage
Damage Assessment & Official Response
Document any structural, equipment, or physical property damage observed:
| Damage & First Responder Details | |
|---|---|
| Description of Property Damage | __________________________________________________ |
| Estimated Cost of Repair | __________________________________________________ |
| Investigating Officer / Fire Department | __________________________________________________ |
| Report Number | __________________________________________________ |
Bodily Injury
Injury & Medical Treatment Details
Complete all fields if an individual sustained personal injury during the incident:
| Injured Person & Medical Assessment | |
|---|---|
| Injured Person Name / Contact Information | __________________________________________________ |
| Injured Person Statement | __________________________________________________ |
| Professional Medical Treatment Required (Y/N) | [ ] YES [ ] NO |
| Medical Facility | __________________________________________________ |
| General Condition / Comments | __________________________________________________ |
Location & Inspection
Location Conditions & Prevention
Evaluate scene conditions and identify preventative steps taken:
| Site Inspection & Corrective Action | |
|---|---|
| Location Inspected (Y/N) | [ ] YES [ ] NO |
| Inspection Date | __________________________________________________ |
| Inspection Time | __________________________________________________ |
| Description of Location Conditions | __________________________________________________ |
| Corrective Actions / Prevention Measures | __________________________________________________ |
Attachments & Submission Sign-Off
Documentation Checklist & Signatures
Required Attachments: Photos, witness statements, maintenance records, or other supporting documentation.
Submission Instructions: Within 24 hours of an incident, please provide a signed report to Josh Page, Director of Operations (Josh@riseselect.com). If an incident involves employees, please complete relevant First Report of Injury documentation using your state-specific form and provide a copy to Josh@riseselect.com and HR@riseselect.com.
| Report Verification Sign-Off | |
|---|---|
| Submitted by (print) | __________________________________________________ |
| Report submitted date | __________________________________________________ |
| Signature | __________________________________________________ |
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