incident report
incident report
incident report
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INCIDENT REPORT<br />
This form is used to provide information on security or traffic <strong>incident</strong>s. Please type or print clearly and<br />
answer all questions as accurately and completely as possible. Please submit additional comments with this<br />
form if you need more room. If you need to estimate a loss indicate your answer is an estimate by adding<br />
“est” following your entry. Please complete this form as soon after the <strong>incident</strong> as possible so that details<br />
will be fresh in your mind. Contact your Regional/Country Director with any questions. Submit the form to<br />
Thughes@ird-dc.org within 24 hours.<br />
Country & Site<br />
Date of Incident<br />
Time of Incident (Local)<br />
Incident Number<br />
Type of Incident<br />
(Check all that apply)<br />
Threat/Intimidation<br />
Vehicle Accident<br />
Petty Theft<br />
Personal Assault<br />
Demonstration<br />
Sexual Assault<br />
Vandalism<br />
Robbery<br />
Surveillance<br />
Ambush<br />
Hostage Taking<br />
Riot<br />
Fire/Arson<br />
Killing<br />
Hold-Up<br />
Other<br />
Was property taken? If yes describe:<br />
(MM/DD/YY)<br />
(HH:MM)<br />
International Staff<br />
Local Staff<br />
Injured<br />
Injured<br />
Killed<br />
Killed<br />
Civilians Injured<br />
Civilians Injured<br />
Civilians Killed<br />
Civilians Killed<br />
Location of Incident: (Please attach a diagram)<br />
Description of Injuries: (Of all parties or effected bystanders if known)
Incident Description: (Please describe in your own words exactly what happened leading up to,<br />
during and just after the <strong>incident</strong>, try to be as detailed as possible. Attach additional sheets is more room<br />
is required)<br />
Perpetrators<br />
How many Perpetrators did you observe?<br />
Do you think you know the Perpetrator?<br />
(Give Names)<br />
What were they wearing?<br />
What language did they use?<br />
What types of weapons did they have?<br />
(Number and types i.e. 2x pistols, 1x rifle)<br />
What other types of equipment?<br />
(Radios, mobile phones etc.)<br />
Number & types of vehicles?<br />
(make, color, number plate, distinguishable damage<br />
or marks)<br />
What do you think was their motive?<br />
Did they appear well organized or<br />
disorganized?
Did you observe any significant tactics in<br />
the <strong>incident</strong>? If so what?<br />
Do you recall any indicators prior to the<br />
<strong>incident</strong>? (Warnings, surveillance, etc)<br />
Local Response<br />
Where the local authorities notified?<br />
(If yes who? give name)<br />
What time were they notified?<br />
What time did they respond?<br />
What recommendations can you make to<br />
help colleagues avoid this type of <strong>incident</strong><br />
in the future?<br />
Please provide names and contact<br />
information for anyone you know<br />
witnessed this <strong>incident</strong>.<br />
Reported by (name)<br />
Work Phone<br />
Home/Cell Phone<br />
Signature of<br />
victim/informant<br />
Name of person<br />
writing <strong>report</strong> if<br />
different from above<br />
Contact Information<br />
Radio Channel<br />
Call Sign<br />
Today’s Date<br />
Country Office/Security Report<br />
Report received by<br />
(Name and Date)<br />
Incident site investigated by<br />
(Name and Date)<br />
Rate credibility of information 1-10 and<br />
comment.<br />
Rate reliability of information 1-10 and<br />
comment<br />
Is a follow up required?<br />
(explain)<br />
Investigator’s comments:
Date <strong>report</strong> sent to HQ:<br />
Date received by HR:
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