PIR ID

Incident Report Form - Public

The provision of this claim form is not an admission of liability on the part of Council
All questions must be fully answered
The person involved in the incident must complete this form
If not the person involved, the declaration must be signed.

Privacy

The information collected in this form will be used by Council in assessing this report in compliance with Councils Privacy policy.

Details of Person involved

Name

First Last

Address

Street Address City State

Phone

Email

Age

16+

Under 16

Parent/Guardian Details

Name

First Last

Address

Same as previous

Street Address City State

Phone

Email

Details of the incident

Incident Date

Incident Time

:

Incident location

Enter the address or approximate address of the incident. This will automatically move the marker on the map to the location and you can drag it to a more precise location if required.

Incident Map

Hidden

Geocoder

Surface Type

Surface Condition

Lighting

Weather at the time of the incident

Was the incident reported to Police?

Yes

No

Did Police attend the scene of the incident?

Yes

No

Police Event Number

Description of the incident

State fully and clearly what happened

What activity was being undertaken at the time of the incident?

What do you think caused the incident?

Who do you think is responsible for the incident? Why?

Additional Incident details

Tick all that apply

Incident involved property damage

Incident involved physical injury to a person

There was a witness to this incident

I have photos of the scene/damage available for council use?

Scene/Damage photos

Please upload photos

Drop files here or

Accepted file types: jpg, jpeg, gif, png, Max. file size: 30 MB, Max. files: 10.

Property Damage

Nature and extend of damage:

Estimated Cost:

Owner Name

First Last

Owner Address

Street Address City State

Owner Phone

Physical Injury

Was medical assistance sought?

If first aid received, what was given and by who?

Type of injury

Part of the body injured?

Witness Details

Name

First Last

Address

Street Address City State

Location of witness at time of incident

Witness Statement

Additional Information

This section can be used to provide any additional information relevant to the report. Click next once you are finished adding information.

File Upload

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 30 MB, Max. files: 10.

File details

Any other details

Person completing this form

Contact Name

First Last

Contact Phone

Signature

If not the affected person, what is your relationship with the affected person?

Email Address(Required)

Hidden

Submission Date

Comments

This field is for validation purposes and should be left unchanged.

Public Incident Report

Incident Report Form - Public

Details of Person involved

Parent/Guardian Details

Details of the incident

Property Damage

Physical Injury

Witness Details

Additional Information

Person completing this form