NYLO Dallas/Las Colinas Incident Report

Section 1: General Information (Injured Party/Complainant) Last Name First Name

Employee (fill in dept. and position) Hotel Guest (Room#_______) Bar/Rest. Guest

Department Daytime Phone Number Is injured party or complainant under the age of 18? If so, name of parent or guardian
Section 2: Description of the Event Date of Event

Position Evening Phone Number Yes No

Date Reported Location of Event

Time of Event Time Reported

What happened? (Description of the event, how it occurred, and any factors that contributed to the event)

What injuries resulted, if any? (Description of injury)

Was medical treatment needed? Yes Was first aid treatment administered? Yes Did injured party go to a hospital/clinic? If so, where did they seek medical treatment? Were the police involved? Yes No Was anyone arrested? Yes No Police Officer's Name/ Badge Number

No No Yes

If so, by whom? No

Police Officer's Phone Number

NYLO Dallas/Las Colinas 1001 Royal Lane; Irving, TX 75039 Telephone 972-373-8900 Fax 972-373-8901

Were there witnesses? Name of Witness #1 (First and last) Phone Signature of Injured Party/Complainant Name of Manager/Supervisor reporting incident Signature of Manager/Supervisor reporting incident

Record any additional witnesses on bottom Name of Witness #2 (First and last) Phone Date Position Date

Section 3: Employee information (to be completed when incident involves an employee)

Job title Date employed

Department Employee's immediate manager/supervisor

Did employee loose time from work? Yes No If "yes", first day of lost time Date employee returned to work If employee sought medical treatment for injury, they must provide a doctor's note for record of injury. Must be complete with work restrictions, if any. Seeking first aid treatment and completion of this report does not waive the employee's right to file a workers' compensation claim and seek benefits in accordance with statutory workers' compensation laws.

NYLO Dallas/Las Colinas 1001 Royal Lane; Irving, TX 75039 Telephone 972-373-8900 Fax 972-373-8901