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Incident Form

This incident and accident report form is used to document any personal injuries, near misses, or dangerous occurrences at a restaurant. It requests details of the date, time, and location of the incident. A description of what happened and whether there were any witnesses is included. Space is provided to record information about any injured individuals, their treatment, and the actions taken to prevent future incidents. The form is completed by a staff member who provides their contact information.

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kenandkara
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80 views

Incident Form

This incident and accident report form is used to document any personal injuries, near misses, or dangerous occurrences at a restaurant. It requests details of the date, time, and location of the incident. A description of what happened and whether there were any witnesses is included. Space is provided to record information about any injured individuals, their treatment, and the actions taken to prevent future incidents. The form is completed by a staff member who provides their contact information.

Uploaded by

kenandkara
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Incident & Accident Report Form

Use this form to report any personal injuries, near misses and any dangerous occurrences which take place on restaurant premises.

DETAILS OF THE ACCIDENT / INCIDENT

Date Time Location (dining room, kitchen)

Describe the injury or incident:

What happened? How did it happen?

Were there any witnesses? If so, give their contact details (name, phone, address)

WAS ANYONE INJURED?

Name Age  M  F Employer

Address Phone
(If more than one person was injured, complete a separate “Incident & Accident Report Form.”)

TREATMENT DETAILS

 None  First Aid  Outpatient Clinic  Advised to see own GP  Hospital  Hospital Stay? how many nights? .

 Absent from work? how many days?  Other treatment details

ACTION

 What action has been taken to prevent a reoccurrence?

FORM COMPLETED BY:

Name Title Phone

Address Date

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