Investigation Report : Meow Wolf Shrimps

Incident Report #

If populated, this report is related to the stated incident report.

Initial Reporting Information

Type of Incident*

Place of Work*

Creative Studios
Santa Fe LLC
Las Vegas LLC
Denver LLC

Date Incident Occurred*

Time Incident Occurred*

:

Was the incident reported to their immediate supervisor?*

Yes
No

Name of Supervisor*

Who was the incident reported to if other than supervisor?

First Last

Date Incident was reported*

Time incident was reported*

:

Was the incident reported to security?*

Yes
No

Witnesses

Were there any witnesses to the incident?*

Yes
No

Insert witness info*

Name	Contact Info

All witnesses have been offered voluntary witness statement form*

Yes
No

Involved Employee Information

Does the employee appear or show signs of being under the influence of drugs or alcohol?*

If yes contact Kelly Stanton Safety Manager

Yes
No
N/A

General Information

Reference from Initial Report - Incident description

This is what was reported in the initial incident report for reference.

How did the incident occur?

What was the situation and exact location at the time of the incident?

Description of the incident*

Please describe in detail what happened.

Specific location of the incident*

State the item most closely associated with the incident*

(i.e. if you tripped over a curb, the curb is the item)

Observed Conditions*

Select observed condition of work area and environment

Explain "Other" for observed condition of work area and environment*

Request surveillance review*

Yes
No

Is operational training required to perform the task that resulted in the incident?*

Yes
No

Names of person(s) involved including the affected employee*

Was property damage a result of the incident*

Yes
No

State what was damaged (equipment, vehicle, display) including model numbers and any other identifiable information*

State the location of the property damage*

Other related information not mentioned or requested that may be pertinent at this time?*

Photo Upload

Examples: Area/location of incident from multiple angles, any equipment machinery involved in the incident.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB.

Initial Corrective Action Information

Has an initial corrective action been identified*

Yes
No

Describe the initial corrective action required to prevent another incident*

(i.e. contained the area, signage, tagged equipment out of service)

Has the corrective action been implemented?*

Yes
No

If not, what is the date the corrective action is to be completed?*

Hidden

If yes, what date was this completed?

Name and title of employee responsible for completing corrective action*

Welcome

Initial Reporting Information

Witnesses

Involved Employee Information

General Information

Initial Corrective Action Information