Hometown Burger Incident Report Form

• Prepared by

• Location
  Address

• Personnel

• Date/time of incident

  Date

Type of Incident

• Employee

• Guests

• Brief Description of Incident

• Name of Employee / Guest Involved

If an Injury Occurred Fill Out the Information Below:

• Name of Injured Employee

• Title/Position

• Home Address

• Employee Phone Number

• Date of Birth

  Date

• Description of Injury

Injury Severity

• First Aid

• Ambulance

• ER

• Clinic

• Name of Hospital/Clinic

• Describe Type of Treatment

• Had the Employee Returned to Duty?

  Yes

  No

  N/A

• Explanation:

Basic Incident Information

• What was employee doing just before incident occurred?

• What happened? How did incident occur?

• What was the incident?

• What object or substance directly cause the incident?

• Did a fatality occur? (If YES, notify the office immediately!)

  Yes

  No

  N/A

• Date of Death:

  Date

• What could have been done to prevent this incident, and how can it be avoided in the future?

Witness Information:

• Name:

• Phone Number:

• Home Address:

Incidents Reports must be sent to Toby Hidenrite within 24 hours!

• Date of Report Completed:

  Date

• Report Completed By:

• Signature:

  Sign