Date and Time of Accident

Location (Area)

• Aisle

• Checkout Counter

• Stockroom

Reporter Name

Job Title

Store 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.

Type of Incident

• Slip, Trip, or Fall

• Falling Object

• Stockroom Accident

• Equipment Malfunction

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.

Was medical attention provided?

Immediate Actions Taken

Describe actions taken to address the incident, such as securing the area, first aid, or repairs.

Was the incident reported to a manager?

• Yes

• No

Manager Name

Phone Number

Additional Comments

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