EcoSet Incident Report "*" indicates required fields Employee contact* First Last Employee email* Employee phone*Date of incident* Month Day Year Time of incident* Hours : Minutes AM PM AM/PM List witness(es)* Incident type* Materials Oasis visitor Space rental client Safety / injury related Security / outside threat Vehicle accident or damage Property damage Brief description of incident*10 words or less. More details will be required on another page. MATERIALS OASIS VISITORVisitor name* First Last Visitor email Visitor phoneDetailed description of incident involving a Materials Oasis visitor*SPACE RENTAL CLIENTType of space rental client* Temporary Ongoing Space rental client name* First Last Space rental client email Space rental client phoneDetailed description of incident involving a rental client*SAFETY / INJURYInjured person* First Last Injured person email Injured person phoneWas an ambulance or hospitalization necessary?* Yes No Was this preventable?* Yes No What could've prevented this incident?* Was first aid administered at the time?* Yes No Describe first aid treatment* Was an Urgent Care visit required?* Yes No Describe outcome of Urgent Care visit* Urgent Care location and payment notes* Is ongoing treatment required?* yes no Detailed description of safety incident or injury*Include location of occurrence, activity engaged in, areas of the body impacted, response by EcoSet staff or crewSECURITYUse this form for crime, vandalism or security threats from an outside entity.Is there security camera footage of the incident?* Yes No What was captured in the footage?Download clips and save for reference Detailed description of security incident or outside threat*VEHICLE ACCIDENT OR DAMAGEVehicles involvedCheck all that apply EcoSet owned vehicle EcoSet rental vehicle Employee vehicle Other driver’s vehicle Multiple other drivers’ vehicles EcoSet vehicle involved* 2013 Mercedes Sprinter – 18188G1 2015 Ford F350 – 31818J3 2020 Isuzu NPR – 42241B3 2023 Ford E-Transit – 01091R3 Was property damaged by a vehicle?* Yes No If yes, complete PROPERTY DAMAGE section belowEcoSet rental vehicle vendor* Rental vehicle make / model / license plate Found on rental agreementEcoSet driver nameIf different than Employee contact above First Last Other vehicle license plate #* Vehicle state on license plate* Vehicle year / make / model* Other driver name* First Last Other driver email Other driver phone*Other driver is owner of the vehicle?* Yes No Owner of vehicle Were there any injuries?* Yes No Who was injured?* EcoSet employee Other driver Name of EcoSet employee, describe injuries* Describe other driver injuries* Was there a key witness to the vehicle incident?* Yes No Vehicle incident witness name* Vehicle incident witness email Vehicle incident witness phone*Address of vehicle incident* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Detailed description of vehicle incident, damage to vehicle*Include location of occurrence, activity engaged in, response by EcoSet staff or crewPolice report obtained?* Yes No Police report #* Attach copy of police report belowContact info photos taken* Photo of other driver’s license Photo of other driver’s DMV registration card Photo of other driver’s insurance info Photo of rental agreement (if not an EcoSet owned vehicle) Vehicle photos taken* Wide shots of accident scene (2-3 angles) Close ups of damage on EcoSet vehicle Close ups of damage on other vehicle Video walk-around of all angles of EcoSet vehicle Video walk-around of all angles of other vehicle PROPERTY DAMAGEProperty damaged* EcoSet property Other offsite property EcoSet property damaged* 3019 Andrita Street 3151 N San Fernando Rd Address of property damage* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Detailed description of property damage*Is there security footage of the property damage?* Yes No Was there a key witness to the property damage incident?* Yes No Property damage witness name* Property damage witness email Property damage witness phone*Police report obtained for damaged property?* Yes No Police report # for damaged property* Attach copy of police report belowSUPPORTING FILESUpload all documents and photos availableIf not uploaded to this report, where are photos, video footage or files available? Attach files to this report Drop files here or Select files Max. file size: 64 MB.