Patron Incident Report

City of St. Catharines employees should complete this report when a member of the public has been injured on City property or exhibited inappropriate behaviour. This form must be completed and submitted within 24 hours of this incident.

Once this report has been submitted, it will go directly to the CAO, Deputy CAO, Director of Corporate Support Services, Director of your Department, Manager of your Division, Human Resources Manager, Human Resources Health and Safety Consultant and Realty and Insurance Services.

Date of Incident

Time of Incident

Name of Patron

Date of Birth

Patron Address

Patron Phone Number

Weather Conditions at time of Incident

Type of Injury / Property Damage

Is Patron on any Medication

Yes

No

Unknown

If yes, list medication(s)

Was First Aid Given

Yes

No

Were emergency services called

Yes an ambulance was called

Yes fire services were called

Yes the police were called

No

Type of Footwear worn by Patron

Patron Comments

Witnesses

Witness #1 Name

Witness #1 Phone Number

Witness #1 Address

Is Witness #1 an Employee or Third Party at the Scene

Witness #2 Name

Witness #2 Phone Number

Witness #2 Address

Is Witness #2 an Employee or Third Party at the Scene

Incident Details

Describe exactly how the incident occurred

Were photographs secured at the scene

Yes

No

If available, up to five different pictures may be attached:

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Date Form Completed

Form Completed by

Employee Name

Employee Phone Number

Supervisor Name

Supervisor Phone Number

If you would like to receive a copy of this report, please enter your e-mail address (City staff only):

The personal information collected on this Incident Form is collected under authority of Municipal Act. This information will be used for the purposes of documenting patron incidents and any necessary follow-up as may be required in accordance with said legislation. Questions about the collection of personal information should be directed to the Office of the City Clerk, or reached at 905-688-5601 ext. 1569 or privacy@stcatharines.ca.

Questions specific to the Municipal Freedom of Information and Protection of Privacy Act, can be directed to the Office of the Clerk (905) 688-5601 ext. 1569 or privacy@stcatharines.ca.