Spa Customer Injury Incident Report
Please complete this form to report any injury incidents involving customers at the spa. Accurate reporting helps ensure proper follow-up and safety.
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident within Spa
*
Please Select
Reception Area
Treatment Room
Sauna/Steam Room
Locker Room
Pool Area
Other (please specify)
Customer Full Name
*
First Name
Last Name
Customer Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Staff Member(s) Involved or Present
*
Describe the Incident
*
Type of Injury Sustained
*
Please Select
Slip/Fall
Burn/Scald
Cut/Laceration
Allergic Reaction
Other (please specify)
Specific Location of Injury on Body
*
Immediate Actions Taken (First Aid, Emergency Services, etc.)
*
Were there any witnesses?
*
Yes
No
If yes, please list witness names and contact information
Follow-up Actions or Recommendations
Signature of Person Completing Report
*
Submit Report
Submit Report
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