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Citizen Incident Report
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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.
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Date of Incident (mm/dd/yyyy):
Time of incident:
Please further identify time of incident:
Exact Location of Incident:
List All Witnesses: (Please include name, address and phone number, if known.)
Was First-Aid Given?
Type of First-Aid Given (if applicable): (Please include name, address and phone number of those who gave first aid)
Please provide the date and time that any first aid treatment was given:
Was Medical Emergency Treatment Given?
If medical emergency treatment was given, what paramedics/hospital/doctor provided it? (Please give names, address and phone numbers for all treatment providers.)
Please provide the date and time that any medical emergency treatment was given:
Any Other Comments:
Please sign and date below.
Please return the completed form by clicking either Submit or Submit and Print below, or by mailing to:
Village of Lombard
ATTN: Village Manager's Office
255 E. Wilson Ave.
Lombard, IL 60148.
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