Free Customer Injury Report Form Template
Customer Injury Report Form
Please complete this form to report any injuries sustained by a customer on the premises.
Date and Time of Accident
Location (Area)
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Entrance
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Aisle
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Checkout Counter
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Customer Name
Phone number
Address
Incident Description
Provide a detailed description of the incident, including the events leading up to, during, and after the injury.
Type of Incident
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Slip, Trip, or Fall
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Injury caused by falling object
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Collision with furniture/equipment
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Reaction to hazardous substance (e.g., cleaning chemicals, food allergy)
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Witness Name 1
Phone number
Witness Name 2
Phone number
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Were there any injuries?
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Yes
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No
Description of Injuries
Describe the type and severity of the injury, e.g., sprain, cut, or bruise.
Was medical attention provided?
Immediate Actions Taken
Describe actions taken to assist the customer, such as first aid, notifying emergency services, or cleaning the area.
Was the incident reported to a staff member?
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Yes
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No
Staff Member's Name
Phone Number
Additional Comments
Include any further information, suggestions, or recommendations to prevent future occurrences.
|
Customer |
[Your Name] Staff Member |
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