Incident Report
What is your name?
*
First Name
Last Name
Who was the Manager on Duty at the time of the incident?
*
What is your store number?
*
The four-digit number assigned to your store.
Type of Accident
*
Auto Accident - please select if team member(s) involved in an auto accident.
Commissary Incident - please select for an incident that occurred with commissary.
General Liability - please select this if none of the above apply.
Property Damage - please select if property damage occurred.
Robbery - please select if any form of robbery occurred.
Team Member Injury - please select if team member(s) were injured while on the job.
Incident Details
Please include as much detail as possible in the report.
Team Member's Name
*
First Name
Last Name
Team Member's Phone Number
*
Please enter a valid phone number.
Date of Incident
*
-
Month
-
Day
Year
Date
Time of Incident
*
Hour Minutes
AM
PM
AM/PM Option
Date Incident Reported to Management
*
-
Month
-
Day
Year
Date
Location of Incident
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Detailed Narrative Description of Incident
*
Where there any witnesses?
*
Yes
No
Name of Witnesses
*
Witnesses' Contact Information
*
Were the police contacted?
*
Yes
No
Name of the Police Department that responded.
*
What is the case number?
*
If no case number was issued, please type No Case Number Assigned
Team Member Injury
Please include as much detail as possible in the report.
Where did the injury occur?
*
In Store
On Delivery
Did the team member seek medical treatment outside of first aid?
*
Yes
No
What body part was injured on the team member?
*
What medical facility did the team member seek medical treatment?
*
If you are unsure of the medical facility name, please type "Medical Facility Name Unsure."
Auto Accident
Please include as much detail as possible in the report. Team members involved in an accident are NOT AUTHORIZED to drive until all documents are submitted and approved by HR.
Year of team member's vehicle
Make of the team member's vehicle
Model of team member's vehicle
Where on the road did the accident occur?
*
Parking Lot/Private Property
Public Road
Intersection
Was the team member's vehicle damaged?
Yes
No
Was a MAC Pizza team member injured?
Yes
No
Was another driver(s) involved in the accident?
Yes
No
Other Driver's Name
Other's Driver's Phone Number
Please enter a valid phone number.
Other Driver's Vehicle Year
If you are unsure of the other driver's vehicle year, please type "Unsure."
Other Driver's Vehicle Make
If you are unsure of the other driver's vehicle make, please type "Unsure."
Other Driver's Vehicle Model
If you are unsure of the other driver's vehicle model, please type "Unsure."
Other Driver's Insurance Company Name and Policy Number
If you are unsure of the other driver's insurance company and policy number, please type "Unsure."
Was the other driver injured?
Yes
No
Please upload any photos of the vehicle(s) involved.
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Team members that were involved in an accident are NOT AUTHORIZED to drive until all documents are submitted and approved by HR. Please don't forget to submit a Post AA VI to HR.
Robbery
Please include as much detail as possible in the report.
Was MAC Pizza property stolen? (hot ag, car topper, bank, etc.)
*
Yes
No
Does the stolen company property need to be replaced?
*
Yes
No
Did a MAC Pizza team member have any personal property stolen?
*
Yes
No
Was a MAC Pizza team member injured?
Yes
No
Please provide a detailed list of any items stolen.
Property Damage
Please include as much detail as possible in the report.
Please describe the damage that was done and how it happened.
Were photos taken of the property damage?
*
Yes
No
Have any repairs been made to the damaged property?
*
Yes
No
Has a Corrigo been submitted for repairs?
*
Yes
No
General Liability
Please include as much detail as possible in the report.
Detailed Narrative Description of Incident
Commissary Incident
Please include as much detail as possible in the report.
Location of the Incident:
Where did the incident take place? Inside the store or outside of the store? Please give as much detail as possible.
Nature and Extent of Property Damage:
What type of damage occurred?
Actions taken to Contain/Control the Incident or Damage:
Was a Corrigo submitted for repairs? Has your DM been contacted?
Name of the Commissary Driver:
If you have this information, if not please type N/A.
Driver ID:
If you have this information, if not please type N/A.
Delivery Truck Number/Registration (if any):
If you do not have this information, please type "This information was not available to me" in this field.
Trailer Fleet Number/Registration (if any):
If you do not have this information, please type "This information was not available to me" in this field.
Please upload photos of any damage done.
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