CUSTOMER ACCIDENT/INCIDENT REPORT
CUSTOMER ACCIDENT/INCIDENT REPORT
Instruction: This form must be completed by the store manager whenever an accident/incident occurs. The assistant manager or authorized designate for the store will be responsible for completing this form in the absence of the store manager. The store manager must ensure a copy of the completed report is forwarded to the Human Resources Manager.
Date of Report: ____________________________________________
Store Location:________________________________________________
Date of Accident: ______________ Exact Time of Accident: ______ A.M./P.M.
Name of Manager on duty at time of accident: _________________________________________
Name of Store Employee who completed this report: ____________________________________ 1. Did you witness accident/incident? Yes No 2. If not, who informed you of the accident? ____________________________________
Outside weather conditions: (circle all that apply): Clear, Cloudy, Raining, Snowing, Windy, Light, Dark Other___________________________________________________________________ ________________________________________________________________________ Exact location of accident/incident at store ________________________________________________________________________ Description of Accident or Incident: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Did you inspect location immediately after accident/incident? Yes No Exact Time of inspection: ____________ Number of photographs taken of location: _________ Was location clean? Yes No Dry? Yes No Any signs Posted?____________________________________________________ _ When was the last time the area was cleaned? __________ By whom? __________________________ When was the last time the area was checked? _________ By whom? __________________________ Describe lighting conditions: _____________________________________________________________
INJURED PERSON INFORMATION Name of person injured: ________________________________________________________________ Home Address: _______________________________________________________________________
_______________________________________________________________________
Home Phone #:_____________________________
Work Phone #:__________________________
Age or Date of Birth:______________________ Was injured person wearing glasses? _____________________________________________________ Type of footwear injured person was wearing: _______________________________________________ Describe Injury: _______________________________________________________________________
Describe medical care at scene (if any) & name of doctor, hospital or clinic: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Name of injured person's companion, if any:
________________________________________________ Address: _______________________________________________________________________
________________________________________________________________________
Home Phone #: ______________________________
Witnesses, if any: Name: ________________________________ Name: __________________________
Address: ______________________________ Address: _________________________
Phone #: ______________________________ Phone #: __________________________
Signed by Supervisor___________________________Supervisor's Name _____________________________
Signed by Person Involved:______________________Signed by HR:_________________________________
Signed by Store Manager:______________________Date:________________________________________
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