Customer Injury Report
Must be completed within 24 hours
Form Submission Number
Date Injury Reported
*
-
Month
-
Day
Year
Date
Customer Name
*
First Name
Last Name
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Address of store where Incident Took Place
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Accident
*
-
Month
-
Day
Year
Date
Time of Accident
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Accident Reported to
*
First Name
Last Name
Description of Accident (to be completed by manager/employee and customer
*
What happened and how did it happen? Was any equipment/property damaged?
Name of Witness to Accident (if any)
*
First Name
Last Name
Was an Ambulance called and if so what hospital were they brought to?
*
Type "No" or "Yes, (Hospital Name)
If there was not an ambulance called, did he/she state they will seek medical attention at a later time?
*
Type Yes or No
Was customer doing something unsafe? (running, climbing, etc.) If yes, explain
*
What Concerns do you have about this injury, if any?
*
Supervisor Name
*
First Name
Last Name
Supervisor Phone Number
*
-
Area Code
Phone Number
Today's Date
*
-
Month
-
Day
Year
Date
Employee Signature
*
Employee Name
*
First Name
Last Name
Employee Number
*
-
Area Code
Phone Number
Employee/Store Email Address
*
example@example.com
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