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

                Email

                  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

                            Email

                              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:

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