Customer Incident Report

This form helps us understand incidents happening at the locations.

Fill it all out.

Today's Date

Manager on Duty

Name (First, Middle, Last)

Name of Parent/Guardian (if under 18)

Physical Address

Telephone Number

Date of Birth

Date and Time of Incident

Specific Location of Incident

Customer’s written description of Incident and conditions

What was customer doing just before incident?

How did the injury occur?

Customer’s written description of complaints/injuries

Names and actions of all employees involved in responding to the incident

Last inspection of the incident area and by whom

Were pictures taken of the area and any injuries?

Customer Witnesses

(Name, Address, Telephone Number)

Employee Witnesses (Name)

Manager on Duty

By checking this box I (the above named) acknowledge that this information is correct to the best of my knowledge.

Submission Successful!