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Free Customer Injury Report Form Template

Free Customer Injury Report Form

Name: Free Customer Injury Report Form Template
Brand: Template.net
Availability: InStock

Customer Injury Report Form

Please complete this form to report any injuries sustained by a customer on the premises.

Date and Time of Accident

Location (Area)

Entrance
Aisle
Checkout Counter

Customer Name

Phone number

Email

Address

Incident Description

Provide a detailed description of the incident, including the events leading up to, during, and after the injury.

Type of Incident

Slip, Trip, or Fall
Injury caused by falling object
Collision with furniture/equipment
Reaction to hazardous substance (e.g., cleaning chemicals, food allergy)

Witness Name 1

Phone number

Witness Name 2

Phone number

Upload Relevant Files

Were there any injuries?

Description of Injuries

Describe the type and severity of the injury, e.g., sprain, cut, or bruise.

Was medical attention provided?

Immediate Actions Taken

Describe actions taken to assist the customer, such as first aid, notifying emergency services, or cleaning the area.

Was the incident reported to a staff member?

Staff Member's Name

Phone Number

Additional Comments

Include any further information, suggestions, or recommendations to prevent future occurrences.

Customer

[Your Name]

Staff Member

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Discover the efficiency of the Customer Injury Report Form Template from Template.net. This customizable and editable template is specifically designed to streamline injury reporting for professionals. Fully editable in our AI Editor Tool, it offers seamless adjustments to suit your specific requirements. Empower your team with precision, ease, and a professional edge in documenting incidents effectively.