Incident Report

When an incident arises at the chapter causing any bodily injury or property damage to any person, the following information must be obtained immediately. This report is being completed for submission to our attorney and insurance company, so please be thorough. If the bodily injury is of a serious nature, please call Chief Executive Officer Rex Martin at 916-891-9200 ext. 118 or Senior Director of Operations Grant Bargfrede at 816-891-9200 ext. 120.

Date of Incident *

Month

Day

Year

Chapter *

Address *

Country *

Address 1 *

Address 2

City *

State *

ZIP code *

Noble Ruler *

Noble Ruler's Phone Number *

Noble Ruler's Email *

Adviser *

Adviser's Phone Number *

Adviser's Email Address *

Alumni Corporation President *

Alumni Corporation President's Phone Number *

Alumni Corporation President's Email *

Name of Injured Party *

Phone Number of Injured Party *

Witnesses and Phone Numbers *

Description of What Happened (What, When, Where, How Much, etc.) *

Incident Report

Audience

Action

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