HTML Preview Incident Form page number 1.
Incident Report Form Template
MATP INCIDENT REPORT
NAME OF INVOLVED PERSON ________________________________________
A
DDRESS ______________________________________________________
_____________________________________________________
P
HONE _______________________ AGE ________ SEX ________
DATE & TIME OF INCIDENT _________________________________________
LOCATION _______________________________________________________
WAS ILLNESS OR INJURY INVOLVED (if yes, describe below)? __________
DESCRIPTION OF INCIDENT (Please include names of individuals involved, nature of the
incident, if injury or illness give name of physician/hospital used, names & addresses
of witnesses, and narrative of what occurred)
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FINAL MATP DISPOSITION (how you intend to handle the incident, any next steps
required, or likely outcomes)
NOTE: Immediately following the incident, notify the MATP Office by telephone.
Incident Report Forms MUST be completed and submitted by FAX within 48 hours of
the incident. Address the call and FAX to either your MATP Advisor or Program
Manager. The MATP FAX Number is 717-705-8112.