2015 Guest Injury Form

Information

FIRST: FIND OUT IF THE GUEST REQUIRES MEDICAL ATTENTION AND CALL AN AMBULANCE IF NECESSARY.

SECOND: GET INFORMATION FROM THE GUEST ON WHAT HAPPENED.

Provide the guest with Chelsea Stroud's business card so the guest knows who to call for further information or to file a claim.
What is the date and time of the incident?
Guest's name
Guest's Address including street, city and zip
Guest's cell phone number:
Guest's home phone:
Describe what happened.
Was guest injured?
Describe the injury and specific body part injured. For example: cut/bump/burn to left inside elbow 1/4th centimeter in diameter.
If it was a slip and fall, what kind of shoes is the guest wearing? (high heel, open toe, sneaker, etc.)
Was medical attention given?
Describe
Was ambulance called?
Which hospital was guest taken to?
Who made the call?
Time of call:
Was law enforcement called?
Time guest arrived (am/pm0
Time guest departed (am/pm)
Physical description and age (in your estimation)
Weather today and at the time of the incident:
Number of guests at the table:
Name of manager on duty
Server
How did the guest contribute to the injury? (If unknown leave blank)
Was guest's id checked?
If yes, by whom?
Level of intoxication. 0= no signs of intoxication 3 = visibly intoxicated/impaired
Number of alcoholic beverages served to guest:
Names of beverages served:
What meal was served to the guest?

Witness #1: Name and address and phone
Witness #2: Name and address and phone
Witness #3: Name and address and phone
Witness #4: Name and address and phone
Did you obtain written witness statements from each witness (guest or employee)?
Take a photo of the witness statement to include it in this report. MAKE SURE IT CAN BE CLEARLY READ.
If you choose, you can have EMPLOYEE witnesses write their statements at the end of this report rather than on paper. The questions for employee witnesses are after you complete and sign the form.

Photograph the server chart that shows which servers were working which stations. MAKE SURE IT IS A CLEAR PHOTO.
Photograph the guest's ticket. MAKE SURE IT IS A CLEAR PHOTO.
Draw a diagram to illustrate what occurred, or where it occured, or anything else that would be helpful.
Photos often help someone who was not there better understand what occured. For example, a photo of the area. Or a photo of an item. Note: if you are photographing a puddle, piece of glass or other item please place something next to it for context. For example put a coin or a pen next to it in the photograph.
Include any other information or comments:
Sign your name here (Person who wrote this report)
I have gathered and sent chelseas@ironhillbrewery.com ANY OTHER documentation that would be helpful in this case:<br> - a copy of the schedule showing all employees working <br> - a copy of the time clock report<br> - notes from Bassecamp<br> - a copy of the Clean Floor Log
Save this report then email it directly to chelseas@ironhillbrewery.com and lorraines@ironhillbrewery.com and your restaurant's safety committee representative.

Employee (witness) name:
Employee's position:
Employee's cell phone number:
If employee wrote witness statement on paper, take a picture of the witness statement. MAKE SURE IT IS CLEAR AND READABLE. If witness statement is attached, then do not answer the next questions, instead send report to Chelsea.
Date and time of incident
Describe the location where the incident took place. What was the condition of the area?
Location of witness at time of incident:
Draw a diagram to show where you were at the time of the incident.
Describe what you saw and heard in as much detail as possible.
Employee witness signature:

Employee (witness) name:
Employee's position:
Employee's cell phone number:
If employee wrote witness statement on paper, take a picture of the witness statement. MAKE SURE IT IS CLEAR AND READABLE. If witness statement is attached, then do not answer the next questions, instead send report to Chelsea.
Date and time of incident
Describe the location where the incident took place. What was the condition of the area?
Location of witness at time of incident:
Draw a diagram to show where you were at the time of the incident.
Describe what you saw and heard in as much detail as possible.
Employee witness signature:

Employee (witness) name:
Employee's position:
Employee's cell phone number:
If employee wrote witness statement on paper, take a picture of the witness statement. MAKE SURE IT IS CLEAR AND READABLE. If witness statement is attached, then do not answer the next questions, instead send report to Chelsea.
Date and time of incident
Describe the location where the incident took place. What was the condition of the area?
Location of witness at time of incident:
Draw a diagram to show where you were at the time of the incident.
Describe what you saw and heard in as much detail as possible.
Employee witness signature:

Employee (witness) name:
Employee's position:
Employee's cell phone number:
If employee wrote witness statement on paper, take a picture of the witness statement. MAKE SURE IT IS CLEAR AND READABLE. If witness statement is attached, then do not answer the next questions, instead send report to Chelsea.
Date and time of incident
Describe the location where the incident took place. What was the condition of the area?
Location of witness at time of incident:
Draw a diagram to show where you were at the time of the incident.
Describe what you saw and heard in as much detail as possible.
Employee witness signature: