Date and Time of Accident

Location (Area)

• Entrance

• Aisle

• Checkout Counter

Customer Name

Phone number

Email

Address

Incident Description

Provide a detailed description of the incident, including the events leading up to, during, and after the injury.

Type of Incident

• Slip, Trip, or Fall

• Injury caused by falling object

• Collision with furniture/equipment

• Reaction to hazardous substance (e.g., cleaning chemicals, food allergy)

Witness Name 1

Phone number

Witness Name 2

Phone number

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Were there any injuries?

• Yes

• 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?

• Yes

• No

Staff Member's Name

Phone Number

Additional Comments

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