Incident Report Form
Please fill out this form for any incidents that happen in store
Name of person completing the form
*
First and Surname
Name of person who was injured
*
If filling out for a team member
Injured team members role
*
Name of Work Location (Store/Factory)
*
Date of incident
*
-
Month
-
Day
Year
Date
Time of incident
*
Hour Minutes
AM
PM
AM/PM Option
Type of incident
*
Please Select
Near Miss ( No injury)
First aid injury- on site treatment provided
Medical Treatment injury - had to see a doctor or ambulance called
Lost Time Injury (lost at least one full shift)
Customer incident
Theft
Please select one
Exact location of incident
*
Description of incident
*
As much detail as possible
Exact Bodily Location
*
Example: Burn on left hand
Was any equipment involved in the injury/illness?
*
Example: Coffee machine steaming rod
Witness
*
First and Surname
Date corrective actions completed
Additional Comments
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