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ACCIDENT/INJURY REPORT
FOH Accident Report
To be filled out and submitted by House Manager in the event an audience member sustains an injury
Date of Accident
(Required)
MM slash DD slash YYYY
Time of Accident
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Location:
(Required)
Production
PATRON INFORMATION
Name of Patron
(Required)
Patron who was involved in the accident
First
Last
Phone Number
(Required)
Email Address
(Required)
Table Number
Name of Reservation Holder
The person who who purchased the tickets
First
Last
ACCIDENT INFORMATION
Description of Accident
Description of First Aid Given
Which Emergency Services Were Contacted?
None
EMT
Police
Fire Department
Other (List Below)
Other Emergency Services
Was Any Further Action Taken?
STAFF INFORMATION
Name
(Required)
Staff who responded to incident
First
Last
Staff Phone Number
Staff Email Address
Title
Name
First
Last
Staff Phone Number
Staff Email Address
Title
Name
First
Last
Staff Phone Number
Staff Email Address
Title
REPORT SUBMISSION
Report Submitted By
Date
MM slash DD slash YYYY
Time
Hours
:
Minutes
AM
PM
AM/PM
Liability
(Required)
I submit that all above information is accurate to the best of my knowledge
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About
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