Title Page
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Prepared by
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Report Date
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Date of Incident / Accident
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Location
- Dining Room
- Terrace
- Parking Lot
- Bar
- Coffee/Prep Area
- Kitchen Line
- Kitchen Prep Are
- Dishroom
- Dumpster Area
- Storage Container
- Office
- Walking Cooler
- Walking Freezer
- Walking Beer Cooler
- Men's Restroom
- Women's Restroom
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Manager On Duty
- Leydi Freire
- Yadira Osuna
- Eduardo Zubizarreta
- Daniel Diaz
- Luis Villeda
- Fernando Asencio
Guest/Employee Information & Statement
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First Name
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Last Name
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Telephone Number
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Explanation of the inciden/accident
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Medical Attention
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Medical attention provided by:
- Ambulance
- Fire Department
- Police
- Doctor
- Other
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Other
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Explain if possible treatment admistered
Witness
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Witness 1
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Name
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Phone Number
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Address
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Witness 2
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Name
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Phone Number
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Address
Surveillance/Images
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Video Surveillance Available
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Images Available
Slip & Fall
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Was this a Slip and Fall Accident
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Wet floor sign in place
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Where were they position
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Was the area
- Wet
- Dry
- Freshly Mopped
- Rain Soaked
- Oily
