Incident Report Form
REPORTER INFORMATION
Name of person reporting incident
First Name
Last Name
Phone Number of person reporting incident
-
Area Code
Phone Number
Email
example@example.com
Date incident reported
Date
-
Month
-
Day
Year
Date
INCIDENT DETAILS
Date of incident
Approximate time incident occurred?
Location of incident?
Please Select
MAIN LA PLAZA MALL
KIOSK CROCS
KIOSK NLT
NLT
JURASSIC KARTS
BOUNCE AND FLIP
JURASSIC KARTS MERCEDES
HEB MISSION
Describe precise location of incident
Ex: Location at Main, doors near caramel display
Incident title:
Please Select
(GUEST) INJURY
(GUEST)NEAR MISS
(GUEST)SAFETY CONCERN
CUSTOMER COMPLAINT
(GUEST)ALTERCATION
(GUEST)PROPERTY DAMAGE
(STAFF)NO CALL/NO SHOW
(STAFF) INJURY
(STAFF) ATTENDANCE VIOLATION
(STAFF)POLICY VILOATION
(STAFF)PREFORMANCE CONCERN
(STAFF)EMPLOYEE ALTERCATION
(STAFF)VOLENTARY RESIGNATION
(OPS)EQUIPMENT MALFUNCTION
(OPS)EQUIPMENT MISUSE(GUEST)
(OPS)EQUIPMENT MISUSE(STAFF)
(OPS)FACILITY HAZARD
POWER (OPS) OUTAGE/TECHNICAL ISSUE
(OPS)CASH HANDLINGDISCREPANCY
(OPS) THEFT/SUSPECTED THEFT
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
People involved in the incident (include witness names)
First Name
Last Name
People involved in the incident (include witness names)
First Name
Last Name
People involved in the incident (include witness names)
First Name
Last Name
List additional names of people involved / witness names here:
INCLUDE CONTACT INFO IN THIS SECTION SUCH AS PHONE NUMBERS OR EMAILS
INJURY/MEDICAL
Was anyone injured?
Please Select
YES
NO
If yes describe injury below, if injured party is a minor notate below.
If yes, please describe injury:
Was first aid provided?
Please Select
YES
NO
If yes, please enter parent/guardian information below
Was the injured party a minor
Please Select
YES
NO
If yes, please enter parent/guardian information below
Name of parent or guardian
First Name
Last Name
Phone Number parent or guardian
-
Area Code
Phone Number
Medical Care Recommended?
Please Select
YES
NO
EMS Called?
Please Select
YES
NO
Guest/Staff Declined Care?
Please Select
YES
NO
NEAR MISS/SAFETY CONCERN
Describe what almost happened
What prevented the injury?
Was staff present
Was guest instructed on safety?
Was corrective action taken?
Please Select
YES
NO
Describe Corrective action
Specify what, where, when, and how related to the incident
STAFF ATTENDANCE
Employee Name?
First Name
Last Name
Scheduled Shift Date?
Scheduled Shift Time?
Was employee contacted?
Please Select
YES
NO
Did Employee respond?
Please Select
YES
NO
Reason provided
Prior warnings?
Please Select
YES
NO
Manager Action Taken
POLICY/ALTERCATION
Describe incident
Policy Violated if applicable
Witnesses
Was employee coached?
Please Select
YES
NO
Written warning issued?
Please Select
YES
NO
Follow-up required?
Please Select
YES
NO
EQUIPMENT/OPERATIONAL ISSUE
Equipment /Area involved
Equipment condition observed
Coaching, documentation only, ect
Was equipment removed for service?
Please Select
YES
NO
Maintenance notified?
Please Select
YES
NO
Any injury related?
Please Select
YES
NO
CUSTOMER COMPLAINT
Nature of the complaint
Staff involved
First Name
Last Name
Staff involved
First Name
Last Name
Staff involved
First Name
Last Name
Resolution provided
Compensation given?
Please Select
YES
NO
If yes, what type of compensation was provided?
Follow-up required?
Please Select
YES
NO
FOLLOW-UP & CLASSIFICATION
Incident Severity Level
Please Select
MINOR
MODERATE
HIGH RISK
Was this preventable?
Please Select
YES
NO
UNCLEAR
Corrective action implemented?
EVIDENCE
Please attach proof or Photos that will explain the incident (if available)
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Please attach proof or Photos that will explain the incident (if available)
Browse Files
Cancel
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Please attach proof or Photos that will explain the incident (if available)
Browse Files
Cancel
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Please attach proof or Photos that will explain the incident (if available)
Browse Files
Cancel
of
Signature of person reporting the incident:
Submit
Should be Empty: