NCIDENT REPORT
LOCATION: ______DATE & TIME OF REPORT: ______
***NOTE***This form should be completed IMMEDIATELY after any incident occurs and faxed or emailed to Tzadik corporate office
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DATE OF INCIDENT: ______TIME:______A.M. / P.M.
MANAGER/SUPERVISOR ON DUTY: ______
BUSINESS TELEPHONE #: ______HOME TELEPHONE #: ______
NAME & ADDRESS OF LOCATION OF INCIDENT: ______
______
NAME: ______HOME PHONE: ______
ADDRESS: ______BUSINESS PHONE: ______
______
EMPLOYEE WITNESSES? Y or N IF SO, LIST NAME & PHONE NUMBERS: ______
______
OTHER WITNESSES? Y or N IF SO, LIST NAME, ADDRESS & PHONE NUMBERS: ______
______
______
POLICE CALLED? Y or N IF YES, WHAT DEPARTMENT? ______
CASE NO. ______INVESTIGATING OFFICER: ______
911 CALLED? Y or N IF SO, BY WHOM? ______
WHO RESPONDED? ______
WAS PERSON TRANSPORTED TO HOSPITAL? Y or N
DESCRIPTION OF INCIDENT: ______
______
______
______
TYPE OF INJURIES: ______
ALLEGATIONS/COMMENTS MADE BY CLAIMANT: ______
______
______
APPROXIMATE AGE OF GUEST: ÿ 0-10 ÿ 11-20 ÿ 21-45 ÿ 46-60 ÿ61-75 ÿ over 75
EXACT LOCATION WHERE INCIDENT OCCURRED ON PROPERTY: ______
______
TYPE OF LIGHTING IN AREA: ______
LIGHTING: ÿ not working at time of incident ÿ none in area ÿ bright ÿ dim ÿ sufficient
ÿ other: ______N/A______
TYPE OF WALKING SURFACE (FOR SLIP/TRIP & FALL) WHERE INCIDENT OCCURRED:
ÿ concrete (unpainted or painted?) ÿ carpet (texture & color):______
ÿ mat (rubber or carpet upper?) color:______ÿ wood floor
ÿ laminate ÿ paved surface (black top)
ÿ other: ______
CONDITION OF SURFACE AT TIME OF INCIDENT:
ÿ dry ÿ wet ÿ grease ÿ clean
ÿ object on floor (describe):______ÿ substance on floor (describe):______
TYPE OF SHOES BEING WORN BY CLAIMANT (FOR SLIP/TRIP & FALL) AT TIME OF INCIDENT:
ÿ leather soles ÿ rubber soles ÿ high heels ÿ medium heels
ÿ low heels ÿ sandals ÿ closed shoe ÿ athletic shoe
ÿ other: ______
ANY DEVICES USED BY CLAIMANT? ÿ none ÿ cane
ÿ crutches ÿ walker ÿseeing eye dog ÿ eyeglasses
ÿ other:______N/A______
ATTITUDE OF CLAIMANT:
ÿ embarrassed ÿ apologetic ÿ angry ÿ expressed self-responsibility
ÿ blamed insured ÿ other:______
CONDITION OF CLAIMANT AFTER INCIDENT:
ÿ no apparent injury ÿ walking but limping ÿ needed assistance to leave
ÿ taken away on stretcher ÿ other:______
PHOTOGRAPH OF INCIDENT AREA TAKEN? Y or N
GENERAL REMARKS: ______
REPORT COMPLETED BY: ______