Incident Report AAR Form

INCIDENT REPORT — AFTER ACTION REPORT (AAR)

RECITALS

WHEREAS, Reporting Party: observed or became aware of an incident described herein; and

WHEREAS, Approving Authority: requests a formal after-action review to determine facts, causes, corrective actions, and follow-up responsibilities;

WHEREAS, the parties agree to document findings and recommended actions in this Incident Report AAR in accordance with organizational policies and applicable law.

INCIDENT IDENTIFICATION

Incident ID:    Date (Day):   Month:   Year:

Injury    Property Damage    Security/Breach    Operational Failure    Other (specify below)

REPORTING PARTY

SCOPE OF REVIEW / INVESTIGATION

FACTS, ACTIONS, AND EVIDENCE

INJURIES, DAMAGE, AND COSTS

WITNESSES

ROOT CAUSE ANALYSIS & CORRECTIVE ACTIONS

PAYMENT TERMS (IF APPLICABLE)

Agreed Compensation for Investigation:    Payment Schedule:

Late Payment Fee (if applicable):

TERM AND TERMINATION

Start Date — Day:   Month:   Year:

End Date — Day:   Month:   Year:

CONFIDENTIALITY

All non-public information obtained or generated in connection with the investigation and this AAR is Confidential Information. Reporting Party and Approving Authority each agree to: (a) hold Confidential Information in strict confidence; (b) use Confidential Information solely for purposes of investigation, remediation, and related internal training; and (c) not disclose Confidential Information to third parties except to their employees, contractors, legal counsel, insurers, or regulatory authorities who have a need to know and are bound by confidentiality obligations no less protective than those herein. Confidentiality obligations survive termination of this report for a period of three years, unless a longer period is required by law.

GOVERNING LAW

This Incident Report AAR shall be governed by and construed in accordance with the laws of the jurisdiction identified as: without regard to its conflicts of law principles.

ENTIRE AGREEMENT

This document, together with any attachments expressly incorporated herein, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior proposals, understandings, or agreements, whether written or oral. Any amendment or waiver must be in writing and signed by both parties.

CERTIFICATION

The undersigned certify that the facts set forth in this report are true and accurate to the best of their knowledge, and that the AAR recommendations reflect a good faith assessment of causes and mitigations. False statements made knowingly may be subject to disciplinary or legal action.

I certify the above statement

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