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Guest Injury
Report Form
Incident Information
Store Number
Date of Incident
Date of Notification
Store Address
Time of Incident
Manager on Duty
Name of person who notified
Customer Information
Name of Injured Person
Phone Number
Email
Address
City
State
Zip Code
Occupation
Was an Ambulance Called
*
Yes
No
Age
Employer
Was Medical Attention Required?
*
Yes
No
Medical Information
Doctor's Name
Phone Number
Witness Information
Name
Phone Number
Address
Incident Details
Nature of the Incident
Slip / Trip
Illness
Foreign Object in Food
Burn
Cut
Food Allergy
Other
For Slips & Trips
Was a Trip Hazzard Present?
Yes
No
Not Applicable
Was a Caution Sign Present?
Yes
No
Not Applicable
Was the floor wet?
Routine Cleaning
Spill
Rain / Humidity
Slick / Greasy Spot
Not Wet
Not Applicable
Include Guest Description
Was the incident caught on camera?
Include any relevant photos
Upload File
Upload supported file (Max 15MB)
Detailed Description of Accident
Send
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