Tastebuds Employee Incident Report

TASTEBUDS EMPLOYEE INCIDENT REPORT
This form is being filled out for reporting purposes onlyEmployee Sought Medical Attention
Concept & Store#*
Employee Information
Name*
Address*

Street Address

Street Address Line 2

City/Sate/Zip CodeState / Province

Postal / Zip Code
Cell Phone #*
E-mail*
Gender*

MaleFemale
Height
Weight
Date of Birth*

MonthDayYear
Date
Social Security Number*
Employee Position*
Primary language*
Regular assigned department
Average hours worked per day
Average days worked per week
Hourly Rate of Pay
Hire Date

MonthDayYear
Date
Tenure in current position
Employment type*

Full TimePart Time
Incident Information
Date of Incident*

MonthDayYear
Date
Time*

Hour Minutes

AM/PM Option
Date incident was reported*

MonthDayYear
Date
Did the incident occur at the restaurant?*

YesNo - Other address
Phone Number
Phone Number #2
Store address
Employment State
Did the employee speak to a manager at the time of the incident?*

YesNo
Did the employee speak to other employees at the time of the incident?*

YesNo
What type of incident did the employee experience?*

Slip, Trip or FallCutBurnStruck By/AgainstMedical (known/unknown)Other
Cause of Incident - Travelers
How did the incident happen?*
What was the employee doing when the incident occurred?*
What is the suspected nature of the injury or illness?*

AbrasionBleedingBruiseBurn/ScaldConcussionConvulsionCrampDislocationFaintingFractureHeartInhalationInternal InjuryLacerationPunctureScratchShockSprainStrainOther
Nature of Incident Travelers
Part of Body Injured*

AbdomenAnkleBackChestEarElbowFingerEyeFootForearmGeneralHandHipJawKneeLower LegLungsMouthNeckNosePelvisScalpShoulderSkullSpineTeethThighToeWristOther
Part of Body Injured - Travelers
Please specify right or left of body if necessary *
Location of incident*

Back DockBar AreaBreak RoomCook LineDining RoomDish AreaEntranceHost StandParking LotPrep AreaRestroomStairs/RampTable/BoothWalk-In RefrigeratorOther
Did the accident involve a piece of equipment?*

NoYes - What type? (Enter below)
Was the employee trained on the equipment?*

NoYes - If so, when? (Enter below)
Was the area or equipment in good condition/repair?*

YesNo - Explain below
Was the surface wet, oily, slippery, etc.?*

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

YesNo
What type of shoes was the employee wearing & what was the condition of the shoes?*
Describe underlying causes*
Recommended correction action*
Action taken*
Did the employee lose any time from work or are they working modified duty beyond the date of the injury?

YesNo
Is the employee back at work?

NoYes - Enter date returned below
Is there an anticipated return to work date?

NoYes - Enter date below
Return to work status

LightModifiedRegular
Date employee last worked

MonthDayYear
Date
Was the injury fatal?*

YesNo
Do you have any questions or concerns regarding the injury?

YesNo
If yes, what are you questioning?

If injury is work relatedExtent of injuryOther
Did the employee have any prior injuries or pre-existing conditions?

NoYes - Enter details below
Treatment*

UnknownNoneFirst-Aid/Minor On-Site TreatmentDoctor's Office/Walk-In ClinicEmergency RoomHospital/Clinic - Admitted > 24 hrs
Description of medical treatment and date of 1st treatment
Name, address & phone number of treatment facility
Physician Name
Witness Name
Witness Phone Number
Please enter a valid phone number.
Witness Address
Full Name of Person Completing*
Date*

MonthDayYear
Date
Signature*

Clear
Store email address
example@example.com
Supervisor Name
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 EMPLOYEE INCIDENT REPORT

Employee Information

Incident Information

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