Inspection

Victim

Name

Job Title

Store/Department

Work Address

Gender

Contact Number/Email

Alleged Offender(s)

Do you know the person(s) responsible?

Specify Name(s)

Approximate age

Gender

Relationship to the victim/reporting employee
Details of the Incident
Type of Incident

Description of Incident

Description of any injury, illness or property damage

Take/ upload photo evidence of incident, environment, person(s) involved
Date reported to regulatory authority
Completion

Observations and comments

Name & signature of person reporting