TB Employee Incident Report

TASTEBUDS EMPLOYEE INCIDENT REPORT
Concept & Store#
Employee Information
Name
Address

Street Address

Street Address Line 2

City/Sate/Zip CodeState / Province

Postal / Zip Code
Cell Phone #
Format: (000) 000-0000.
Gender
Height
Weight
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number
Employee Position
Average days worked per week
Hourly Rate of Pay
Hire Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Tenure in current position
Employment type
Employment Type - Am Trust
Incident Information
Date of Incident

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Incident

Hour Minutes

AM/PM Option
Time Employee Began Working

Hour Minutes

AM/PM Option
Date incident was reported

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Did the incident occur at the restaurant?

No - Other address
Phone Number
Phone Number #2
Store address
Employment State
Did the employee speak to a manager at the time of the incident?
Did the employee speak to other employees at the time of the incident?
What type of incident did the employee experience?

Other
How did the incident happen?
What was the employee doing when the incident occurred?
Work duty being performed when incident occurred
What is the suspected nature of the injury or illness?

Other
Nature of Incident Travelers
Part of Body Injured

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

Other
Did the accident involve a piece of equipment/chemical?

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

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

No - Explain below
Were safeguards/safety equipment provided?
Were they used?
Was the surface wet, oily, slippery, etc.?

Other
Was there a “warning sign” posted in area?
What type of shoes was the employee wearing & what was the condition of the shoes?
Describe underlying causes
Recommended correction action
Action taken
Is the employee back at work?

Yes - Enter date returned below
Date employee last worked

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If injury was fatal, date of fatality

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Treatment
Name & address of treatment facility
Physician Name & Address
Witness Name
Witness Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Full Name of Person Completing
Title
GM
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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 EMPLOYEE INCIDENT REPORT

Employee Information

Incident Information

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