ARG Incident Report Form

Date of this report(Required)

Date of incident(Required)

Client(Required)

Location(Required)

Initial information provided by(Required)

Brief description of the incident(Required)

Employee(s) Involved

Employee 1

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date hired

Employee classification

Employee's occupation and classification

Training and certifications

Is the employee

Part-Time

Full-time

Time employee reported for work on day of incident

Days employee typically works per week

Was the employee involved or a witness to the incident?

Involved

Witness

Was the employee injured or possibly injured?

Yes

Please describe the injury(ies) identifying which side of the body is referred to along with any symptoms

Please describe any measures taken such as first-aid, including when and by whom

Was a drug test deemed appropriate?

Yes

Please attach documentation supporting the determination of reasonable suspicion and also attach results if a test was administered

Drop files here or

Max. file size: 2 MB.

If reasonable suspicion of substance use is determined, please requisition both a drug and an alcohol test unless the incident was related to covered work and associated DOT regulations.

If appropriate but not administered, please indicate why not

Was another employee involved?

Yes

Employee 2