Incident Form
Idaho Wings Inc Stores
Store
*
Please Select
Nampa 5036
Meridian 5048
Mountain Home 5044
Burley 5052
I need to complete a:
*
Employee Incident form WITH Injury
Employee Incident form NO Injury
Customer Incident form WITH Injury
Customer Incident form NO Injury
BOTH Customer and Employee Incident Form WITH Injury
BOTH Customer and Employee Incident form NO Injury
Manager Completing Form
*
First Name
Last Name
Email of Manager Completing Form
*
example@example.com
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Employee Incident form WITH Injury
Employee Name
*
First Name
Last Name
Employee ID (Find on 7 shifts)
Today’s Date
-
Month
-
Day
Year
Date
Date Incident Occurred
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Time Employee started work
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Employee Name
*
First Name
Last Name
Today’s Date
-
Month
-
Day
Year
Date
Date Incident Occurred
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Time Employee started work
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Position
*
Please Select
Host
Lead Host
Server
Server Trainer
Bartender
Bartender Trainer
Dishwasher
Cook
Prep Cook
Key Lead Manager
Hourly Manager
Date Employment Started
-
Month
-
Day
Year
Date
Employee Name
*
First Name
Last Name
Today’s Date
-
Month
-
Day
Year
Date
Date Incident Occurred
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
ADMIN ONLY: INSURNCE CLAIM # & ADJUSTER INFO
Submit
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Customer Incident form WITH Injury
Today’s Date
-
Month
-
Day
Year
Date
Address of Incident
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date Incident Occurred
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Name of Injured Customer
First Name
Last Name
Customer Address if Known
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Customer Email if Known
example@example.com
Customer Phone Number if known
Please enter a valid phone number.
Format: (000) 000-0000.
Witnesses
Contact for injured Customer
First Name
Last Name
Phone Number for Contact
Please enter a valid phone number.
Format: (000) 000-0000.
Email for Contact
example@example.com
Detailed Description of what happened
Do you have reason to doubt the claim
Yes
No
Reasoning for doubting the claim
Upload any witness statements, photos, security footage.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
ADMIN ONLY: CLAIM # and ADJUSTER INFORMATION
NOTES UPDATE: (use this area to make any updates after sending initial form
Submit Form
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Submit
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