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Incident Report
If an incident or accident has taken place, please fill out the form below to the best of your ability to notify Corn Stock Management.
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About the person involved
Date & Time of the incident
*
Date
Time
Location of the incident
*
Person injured/involved is a(n)
*
Patron
Patron
Cast or Crew Member
Employee
Other
Please explain
*
Their Name
*
First
Last
Their Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Their Phone
Their Email
Details of the incident
Please explain what happened
*
Nature & Extent of Injuries
*
Action Taken
*
First Aid
Ambulance Called
Police Called
Taken to Hospital
Other
What other action was taken?
*
Which Hosptial?
*
OSF
Carle - Methodist
Carle - Proctor
Carle - Pekin
Could this incident been avoided?
*
Yes
No
What actions could have prevented this incident?
*
Witnesses
How many witnesses can attest to the incident?
*
1
2
3
(You would be considered a witness)
Name (Witness #1)
*
First
Last
The person who is filling out this form
Phone (Witness #1)
*
Email (Witness #1)
*
Name (Witness #2)
*
First
Last
Phone (Witness #2)
Email (Witness #2)
Name (Witness #3)
*
First
Last
Phone (Witness #3)
Email (Witness #3)
Submit
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