Employee Injury Incident Report
Report and document any workplace injury incidents involving fast-food employees. Please complete all sections for accurate record-keeping.
Employee Full Name
*
First Name
Last Name
Employee Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employee Job Position or Department
*
Date and Time of Incident
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident (e.g., kitchen, drive-thru, lobby)
*
Please Select
Kitchen
Drive-Thru
Lobby
Restroom
Storage Room
Other
Describe the Incident in Detail
*
Type of Injury
*
Burn
Cut/Laceration
Slip/Fall
Sprain/Strain
Bruise/Contusion
Other
Part of Body Injured
*
Hand/Fingers
Arm
Leg/Foot
Back
Head
Other
Witness Name(s)
Witness Contact Information
Immediate Action(s) Taken (e.g., first aid, called emergency services)
*
Supervisor/Manager Name
*
Upload Photos or Supporting Documents (optional)
Upload a File
Drag and drop files here
Choose a file
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Employee Signature
*
Submit Report
Submit Report
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