Incident Report Form
Date
-
Month
-
Day
Year
Date
Name of person reporting incident
First Name
Last Name
Phone Number of person reporting incident
-
Area Code
Phone Number
Email
example@example.com
Incident title
Please Select
NO CALL/NO SHOW
SAFETY INCIDENT
CUSTOMER COMPLAINT
POLICY VIOLATION
EQUIPMENT ISSUE
EMPLOYEE ALTERCATION
INJURY/ NEAR MISS
VOULUNTARY RESIGNATION
Date of incident? ?
-
Month
-
Day
Year
Date
Approximate time incident occurred?
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Date Reported?
-
Month
-
Day
Year
Date
Location of incident?
Please Select
MAIN LA PLAZA MALL
KIOSK CROCS
KIOSK NLT
NLT
JURASSIC KARTS
BOUNCE AND FLIP
JURASSIC KARTS MERCEDES
HEB MISSION
People involved in the incident( include witness names)
Specify what, where, when, and how employee's behavior and performance was deficient
Immediate response/Action Taken
Was anyone injured?
Please Select
YES
NO
If yes, describe injury
If yes, please describe injury:
Was there any follow up? If yes, please describe communication"
Outcome: Describe outcome of incident.
Coaching, documentation only, ect
What would you like to see happen
Specify what, where, when, and how employee's behavior and performance was deficient
Please attach proof or Photos that will explan the incident (if available)
Browse Files
Cancel
of
Please attach proof or Photos that will explan the incident (if available)
Browse Files
Cancel
of
Please attach proof or Photos that will explan the incident (if available)
Browse Files
Cancel
of
Please attach proof or Photos that will explan the incident (if available)
Browse Files
Cancel
of
Signature of person reporting the incident:
Submit
Describe Incident
Specify what, where, when, and how related to the incident
Should be Empty: