Incident Report
Customer/Employee
Store #
*
Please Select
562: Northern Lights
782: Campus
1567: West 1
1696: Eastland
2062: Maple Canyon
4723: Alum Creek
5100: Harrisburg Pike
5386:Clintonville
5407: West 2
6380: Sunbury
10165: Sinclair
10512: Franklinton
10553: East Broad
14144: Community Park
17683: Maxtown
18112: Lockbourne
20080: Reynoldsberg
26628: James Road
274472: Cassady
34956: New Albany
OFFICE
Manager on Duty Completing Form
*
First Name
Last Name
Date of Incident
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Incident
*
Hour Minutes
AM
PM
AM/PM Option
Date Store Notified
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
General Manager
*
First Name
Last Name
General Managers Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Customer or Employee
*
Please Select
Customer
Employee
Person Name involved in incident
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Guardian Name, if minor
Person's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Person's Work Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Customer's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Police Notified?
*
Please Select
Yes
No
Police Report Number
Detailed Description of Incident
*
Detailed Description of where Injury is on body
*
Witness? If, there was a Witness please list who and their phone # below
*
Was the person injured?
*
Please Select
Yes
No
Did the person receive medical treatment?
*
Please Select
Yes
No
Unsure
How did they get to the Hospital?
*
Please Select
Drove Themselves
Didn’t go to hospital
Transported by Squad
Transported by Ambulance
Someone Drove Them
Document upload: Video, Statements, Doctors Note, Etc
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Date Form Completed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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