Accident Report Form (for associates or customer accidents/injuries)

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Store Number *

Person Reporting Incident / Accident *

First

Last

I am reporting a *

Initial Incident Evaluation – Mark all that apply *

Incident witnessed by others
Was anyone hurt during this incident/accident
Medical attention beyond basic first aid required
Employee transported to a clinic or hospital
Employee saw a doctor
Employee returned to work after the accident
Employee had to miss time from work due to the incident
Employee will need modified duties or work restrictions for more than 7 days
Incident was a “near miss” or hazardous situation that could have caused serious injury
Incident involved a head injury, fall from height, or possible concussion
Any equipment or infrastructure involved or damaged

Initial Incident Evaluation – Mark all that apply *

Was anyone hurt during this Incident/Accident?
Was medical attention beyond basic first aid required?
Was the customer transported to a clinic or hospital?
Did the incident involve a head injury, fall from height, or possible concussion?
Was any equipment or infrastructure involved or damaged?
Was the incident witnessed by others?

Describe the Type of Injury?

Which parts of the body were hurt?

Person Involved in Incident/Accident *

First

Last

Customer Phone Number *

Witness of Incident *

First

Last

Date / Time of Incident *

Date

Time

Location of Incident/ Accident *

Please describe the Incident/ Accident in detail: *

Could this incident/accident been avoided? *

If Yes, explain HOW this accident could be avoided in the future below:

Signature of Reporter *

Clear Signature

Signature of Witness / Injured Party

Clear Signature

Comment