Incident Report Form

Incident Report Form
Store Number*
Employee Name*

First NameLast Name
Date of Accident*

MonthDayYear
Date
Time of Accident*

Hour Minutes

AM/PM Option
Was anyone injured/hurt*

YesNo
Was an ambulance called*

YesNo
Upload the following; -ID from team member -Completed Accident Report*

Cancelof
Supervisor Area*
Submitted by*

First NameLast Name
Position*
Kicka Email
example@example.com
Should be Empty: