Sample Incident Report Form

Date and Time: _________________________________________

Location (i.e., department or area of the library): __________________________________________________________________________

Initial staff person: __________________________________________________________________________

Other staff involved: __________________________________________________________________________

Patron name (if known): ______________________________________________________________

Patron description:

Issue (i.e., stress point):

Resolution:

Notes: (e.g., what the library might do to affect this stress point; what the staff person might do differently next time; request for follow-up by staff member):