Grocery Store Incident Report Form
Grocery Store Incident Report Form
This form must be completed immediately after the incident and submitted to the manager, with all information kept confidential.
Date of Incident
Please select the date you visited our coffee shop.
Time of Incident
1. Incident Details
Where did the incident happen?
What type of incident?
(check one):
-
Slip/Trip and Fall
-
Object Fell
-
Equipment Issue
-
Customer Injury
-
Employee Injury
-
Spill
-
What happened?
(Describe the incident):
2. Injured Person’s Information (If someone was hurt)
Name
Phone number
Address
What type of injury?
(check one):
-
Bruise
-
Cut
-
Sprain
-
Fracture
-
Burn
-
Injury location?
(check one):
-
Head
-
Arm/Hand
-
Leg/Foot
-
Back
-
3. Witness Information (If someone saw the incident)
Name
Phone number
4. Employee Completing Report
Name
Position
Phone number
5. Action Taken (check all that apply)
-
Gave First Aid
-
Called 911
-
Cleaned Up Area
-
Fixed Equipment
-
Notes/Comments
7. Signatures
Reporting Person
Name:
Date:
Manager
Name:
Date:
Thank you for submission!
We appreciate you taking the time to submit.
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