REPORT OF 3RD PARTY INCIDENT

This form is to be completed in the event of a Third Party (customer, guest, or visitor) incident. If a 3rd Party is injured and needs immediate medical assistance, call 911. Remain calm and professional while being supportive to the customer but never directly admit fault.

The information in this form should be gathered and filled in by the on-duty manager. Do not have the 3rd Party fill out any part of this form. Make any additional notes that you feel are pertinent. File this form with any other documents relating to the incident so they can be reviewed at a later date, if necessary.

LOCATION INFORMATION

Address:	City:	State:	Zip Code:

Manager(s) on duty:	Phone:

3RD PARTY INFORMATION

Name(s):

Sex: [ M / F ]	Date of Birth:	Est. Height:	Est. Weight:

Address:	City:	State:	Zip Code:

Home phone:	Work phone:

Nature of injury or property damage:

If there was physical injury, was medical assistance provided? ( YES / NO ) If yes, describe:

Transported for further medical care by: Ambulance:	Private Vehicle:

INCIDENT INFORMATION

Date of Occurrence:	Time of Occurrence:	( A.M. / P.M. )

Exact location of occurrence:

3rd Party’s (customer, client, visitor) description of the incident:

3rd Party’s attitude:

Did 3rd Party appear to be intoxicated / under the influence? ( YES / NO )

WITNESS INFORMATION

Non-employee Witnesses: Record the names and phone numbers of any witnesses to the incident:

[Record witness statements on a separate page and attach to this form.]

Employee Witnesses: Record the names and phone numbers of any Employee witnesses to the incident:

[Record witness statements on a separate page and attach to this form.]

SLIPS & FALLS

Description of surfaces involved. Note its makeup, condition and the existence of any foreign substances:

Did the incident occur outside? ( YES / NO ) If yes, describe the weather conditions at that time. Note any effects the weather had on the surface:

Whether inside or out, describe any preventative measures or warnings in place to alert the customer of a potential hazard:

Describe the customer’s footwear:

Describe what, if anything, the customer was carrying:

If possible, take photos of the surface immediately following the incident.

Report recorded and filed by:	Date:

File a copy for your records, and submit completed form to: