Date and Time of Accident

Location

Specific Location within the Restaurant

Reporter Name

Job Title

Company Name

Phone number

Email

Name of Injured Employee

Incident Description

Provide a detailed account of the incident. Include events leading up to, during, and following the occurrence.

Witness Name 1

Phone number

Witness Name 2

Phone number

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Were there any injuries?

• Yes

• No

Description of Injuries or Damages

Describe the type and severity of injuries. Specify who was injured and their condition.

Immediate Actions Taken

Describe actions taken to address the incident, such as first aid, cleanup, or equipment repairs.

Was the incident reported to a supervisor?

• Yes

• No

Supervisor Name

Phone Number

Additional Comments

Include any further information, suggestions, or recommendations to prevent future occurrences.