SAFETY LOSS PREVENTION Marriott Incident Reporting Application

INCIDENT / ACCIDENT REPORT

Type of Incident: Accident - be specific about what type of situation this was

Location of Incident: be specific (i.e. 3rd floor, south wing or room number etc)

Time andHOW
Date of Incident: / ACCIDENT OCCURRED (Provide detailed information. Continue on
INCIDENT
reverse if necessary)

Details of corrective action taken:

Again be specific about what happened next, if you provided assistance say what it was, if you had to call an
ambulance/doctor administer first aid, state that too.

Details of property lost or damaged including the value:

Detail what it was, for example don’t just say “mobile phone” give details of what was missing and if possible a
replacement value

Person Affected; Guest / Associate / Club Member / Contractor / Visitor / Hotel Premises

If Associate: Job title & Department:

Male / Female Infant 0 – 1 Child 2 – 17 Adult 18 – 65 Senior over 65

Personal details:

Full name: Tel No:

Address: (inc postcode)

If Guest: Room Number: Date of Arrival: Date of Departure:

Witness Details: (If more than one – continue overleaf)

IF THERE IS A WITNESS PUT THEIR DETAILS HERE

Full name: Tel No:

Address; (inc post code)

Male / Female / Associate / Club member / Contractor / Visitor

 SAFETY LOSS PREVENTION Marriott Incident Reporting Application

Recorded on CCTV; Yes / No Location of tape::

Reported to the Police: Yes / No Officer name and number:

Reported to EHO: Yes / No Date reported & to whom:

Was person seen by Doctor:

Hospital conveyed to:

Working days lost:

Ex-gratia offer made: Yes / No

Details:

Claim anticipated: Yes / No

HOW INCIDENT / ACCIDENT OCCURRED: (continued)

Person Reporting: NEED A PHYSICAL SIGNATURE AND NAME PRINTED

Time / Date:

PLEASE ADD ANY INFORMATION THAT WILL BE HELPFUL AND ENSURE ALL EVIDENCE
IS PRESERVED