APPENDIX B
Morrisville Public Library
83 East Main Street
Morrisville NY
Date__________________________ Time__________________________
Place of Incident__________________________________________________________
Name of person(s) involved in incident________________________________________
Was this a person Staff______ Volunteer______ Patron______ Other______
Name and Title of supervisor at the time of incident______________________________
Name(s) of witness________________________________________________________
Description of incident_____________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Was incident a result of illness_________ or accident_________?
Was medical treatment received? _________________________
The above description is an accurate representation of the occurrence of imjury.
Signatures:
Injured Party______________________________________ Date__________________
Witness(es)________________________________________ Date__________________
Supervisor_________________________________________ Date__________________
