Incident Report Form
Store Number
*
Please Select
1637 (Seth Child)
1692 (Andover)
1693 (47th & Broadway)
6311 (Manhattan Tuttle Creek)
6315 (Salina)
6316 (Junction City)
6321 (Augusta)
6327 (Trooper)
6346 (Derby)
6347 (Winfield)
6350 (Seneca)
6364 (Normandy)
6376 (37th & Woodlawn)
6391 (Park City)
6392 (Harry & Rock)
9631 (Huebner)
9635 (Ark City)
9636 (El Dorado)
9637 (Newton)
Employee Name
*
First Name
Last Name
Date of Accident
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Accident
*
Hour Minutes
AM
PM
AM/PM Option
Was anyone injured/hurt
*
Yes
No
Was an ambulance called
*
Yes
No
Upload the following; -ID from team member -Completed Accident Report
*
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of
Supervisor Area
*
Please Select
Jared Pasquarella
Nathan Lloyd
Todd Ebert
Submitted by
*
First Name
Last Name
Position
*
Please Select
AM
GM
Supervisor
Office
Kicka Email
example@example.com
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