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 #
Work/Cell Phone #
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
Store address
Safety Manager’s Name
Did the guest speak to a manager at the time of the incident?

YesNo
Did the guest speak to other guests or employees at the time of the incident?

YesNo
What type of incident did the guest experience?

Slip, Trip or FallObject in FoodStruck By/AgainstMedical (known/unknown)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?

YesNo
Was the guest wearing glasses at the time of the incident?

YesNo
Did the guest consume any alcoholic beverages on the premises?

YesNo
What is the suspected nature of the injury or illness?

AbrasionConcussionFracturePunctureBleedingConvulsionHeartScratchBruiseCrampInhalationShockBurn/ScaldDislocationInternal InjurySprainConcussionFaintingLacerationStrain
Part of Body Injured

GeneralMouthSkullTeethThighJawKneeShoulderLower LegSpineAnkleChestFootLungsToeAbdomenNeckBackScalpPelvisEyeHipEarElbowNoseForearmHandWristFingerOther
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

Parking LotHost StandFoyer/EntranceWaiting AreaBar AreaStairsRestroomPatioTable/BoothWalk WayRampRear/Side EntranceDining RoomOther
Was the area in good condition/repair?

YesNo
If not, explain
Type of walkway surface

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

NoWetOilySlipperyDirtyOther
Was there a “warning sign” posted in area?

YesNo
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?

NoArtificial GlareNatural GlareDim LightingOther
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)

Witness names and contact information (Including employees)Witness statementsFloor chart and location markedRestroom & Floor checklist (Properly filled out)Roster report from shiftCopy of guest check
Name Person Completing—Printed
Date

MonthDayYear
Date
Signature

Clear
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