Team Member Records

Team Member's Name

First Name

Last Name

Date of Incident

MM

DD

YYYY

Incident Category

Incident Description

Describe or summarize the incident. Include detail, context, and/or how this broke an LOC policy.

Action Taken

What action was taken?

Form of Communication

In what form of communication was the action issued?

Team Member & Customers & Others

List all parties involved in the incident and its resolution.