2. Your name:*
4. Today's Date:*
6. Date of Occurrence:*
8. Time of occurrence:*
10. Explanation: (Submit a separate page and turn it in if your text will not fit here)*
12. Persons involved: (names and phone numbers)*
14. Employees present:*
16. Were the police, EMS or KITTCOM notified?*

    1. Yes
    2. No
18. Was the supervisor/director notified*

    1. Yes
    2. No
20. Damage or loss: List items stolen, lost, broken and their value.*
22. Individual(s) description: Information needed for future follow up by police or staff.*
24. Signature: Your supervisor will have you sign a copy this report.
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field