Incident

Date and Time of Incident

Specific Location of Incident

Customer’s written description of Incident and conditions

What was customer doing just before incident?

How did the injury occur?

Customer’s written description of complaints/injuries

Names and actions of all employees involved in responding to the incident

Were pictures taken of the area and any injuries?

Witnesses

Customer Witnesses (Name, Address, Telephone Number)

Employee Witnesses (Name)

Manager On Duty Name

By checking this box I (the above named) acknowledge that this information is correct to the best of my knowledge.

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