TASTEBUDS GUEST INCIDENT REPORT

TASTEBUDS GUEST INCIDENT REPORT

REPORTING PURPOSES ONLY
Guest Information
Name
Address

Street Address

Street Address Line 2

City/Sate/Zip CodeState / Province

Postal / Zip Code
Home Phone #
Format: (000) 000-0000.
Work/Cell Phone #
Format: (000) 000-0000.
Occupation of Guest
Gender
Age
Height
Weight
Incident Information
Date

MonthDayYear
Date
Time

Hour Minutes

AM/PM Option
Weather conditions at time of & prior to incident?
Concept & Store#
Phone
Format: (000) 000-0000.
Store address
Safety Manager’s Name
Did the guest speak to a manager at the time of the incident?
Did the guest speak to other guests or employees at the time of the incident?
What type of incident did the guest experience?

Other
How did the incident happen?
What was the guest doing when the incident occurred?
Was the guest carrying anything (purse or otherwise) at the time of the incident?
Was the guest wearing glasses at the time of the incident?
Did the guest consume any alcoholic beverages on the premises?
What is the suspected nature of the injury or illness?
Part of Body Injured

Other
Please specify right or left of body if necessary
Did the guest make any kind of statement concerning the incident? If so, record what was stated.
Did the guest ask for assistance of any kind? If so, explain.
Did the guest receive assistance from company or building personnel? If so, from whom?
Was there a call for medical assistance? If so, by whom?
Investigation—Follow Up Information
Location of incident

Other
Was the area in good condition/repair?
If not, explain
Type of walkway surface

Other
Was the surface wet, oily, slippery, etc.?

Other
Was there a “warning sign” posted in area?
What type of shoes was the guest wearing & what was the condition of the shoes?
REPORTING PURPOSES ONLY
Was light a factor in the incident?

Other
Was there any clean up of the site spills, dirt, etc done? If so, describe.
Insert Picture(s) of Incident Location (Where appropriate, place a ruler or pen next to suspected cause of incident to show size in relation to area size)
Additional Photo (if necessary)
Additional Photo (if necessary)
Additional Photo (if necessary)
Additional Photo (if necessary)
Back Up Information (Must be emailed separately after form is submitted)
Name Person Completing—Printed
Date

MonthDayYear
Date
Signature
Store email address
example@example.com
Please scan and email any necessary back up documentation to insurance_reporting@tastebudsmgmt.com

This form will be automatically emailed once submitted
Should be Empty:

TASTEBUDS GUEST INCIDENT REPORT

Guest Information

Incident Information

Investigation—Follow Up Information

REPORTING PURPOSES ONLY

Please scan and email any necessary back up documentation to insurance_reporting@tastebudsmgmt.com