Citizen Incident Report

1. This report is to be used by any citizen involved in a vehicle accident or incident occurring on municipal property which may or may not have required first-aid or hospital treatment, or resulted in the citizen complaining of discomfort or damage to private property as a result of the incident.
   

2. <font color=red>*</font> indicates required field

   * indicates required field

3. Name:*

4. Home Telephone Number:*

5. Cell Phone Number:

6. Work Telephone Number:

7. Email Address:

8. Street Address:

9. City, State, Zip:

10. Date of Incident (mm/dd/yyyy):*

11. Time of Incident:*

12. Please further identify time of incident:*
    1. AM
    2. PM

13. Exact Location of Incident:*

14. Describe Accident/Injury:*

15. Describe Vehicle/Property Involved:*

16. List All Witnesses: (Please include name, address and phone number, if known.)*

17. Was First-Aid Given?*
    1. Yes
    2. No

18. Type of First-Aid Given (if applicable): (Please include name, address and phone number of those who gave first aid)*

19. Please provide the date and time that any first aid treatment was given:

20. Was Medical Emergency Treatment Given?*
    1. Yes
    2. No

21. If medical emergency treatment was given, what paramedics/hospital/doctor provided it? (Please give names, address and phone numbers for all treatment providers.)*

22. Please provide the date and time that any medical emergency treatment was given:*

23. Any Other Comments:

24. Please sign and date below.

25. Signature:*

26. Date:

27. Please return the completed form by clicking either Submit or Submit and Print below, or by mailing to:
    Village of Lombard<br>ATTN: Finance Department<br>255 E. Wilson Ave.<br>Lombard, IL 60148.

    Village of Lombard
    ATTN: Finance Department
    255 E. Wilson Ave.
    Lombard, IL 60148.

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28. 1. Receive email copy
29. Email address

30. Submit Submit and Print

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