Retail Public Incident Report

IMPORTANT: THIS FORM MUST BE COMPLETED IN FULL (WITHIN 12 HOURS AFTER THE INCIDENT)

LOCATION ADDRESS:

Store No.

Store:

Location Code:

Address:

City:

State:

Zip:

Phone:

Claim #

(For Insurance Co. Use Only)

Incident Report: IF CHECKED - DO NOT CONTACT CLAIMANT AT THIS TIME – NO APPARENT INJURY

PERSONAL INJURY

PROPERTY DAMAGE

TIME AND PLACE OF ACCIDENT:

Accident Date:

Time:

Day of Week :

Date Reported:

Time:

Store Name:

LOCATION OF ACCIDENT:

Aisle #

To select more than one, click on each of the locations you want to select while holding down the "CTRL" key.

CUSTOMER INFORMATION:

Name:

Birthdate:

If married, spouse's name:

Address:

City:

State:

Zip:

Home Phone:

Employer:

Work Phone:

Comment on following: Wearing Glasses (tinted/shaded), Type of Shoes, Cane, Crutches, Carrying Packages, Pushing Cart, Etc.

DESCRIPTION OF ACCIDENT AS CUSTOMER REPORTED:

INJURIES CLAIMED:

MEDICAL TREATMENT SOUGHT?

Yes No

IF YES, WHERE?

INJURED PERSON’S COMMENTS AND ATTITUDE:

SCENE OF ACCIDENT: DESCRIBE SCENE (NOTE ANY SUBSTANCE ON FLOOR OR CUSTOMER SKID MARKS ETC.)

WEATHER

LIGHTING

PHOTOS TAKEN?

Yes No

BY WHOM:

DATE:

TIME PHOTOS WERE TAKEN

WARNING SIGNS?

Yes No

MATS?

Yes No

OTHER? DESCRIBE

CONTRACT CLEANING?

Yes No

WAS LOT/WALKWAY SHOVELED/ PLOWED AND/OR SALTED?

Yes No

CONTRACT PLOWING?

Yes No

AISLE INSPECTION SWEEP LOG ATTACHED?

Yes No

ADDITIONAL COMMENTS:

WITNESSES:

NAME:

ADDRESS:

PHONE:

CUSTOMER
EMPLOYEE

NAME:

ADDRESS:

PHONE:

CUSTOMER
EMPLOYEE

PRODUCT INVOLVED (SAVE PRODUCT IF POSSIBLE)

PRODUCT NAME:

WHO HAS PRODUCT NOW?

DATE PURCHASED:

EXPIRATION DATE:

RECEIPT ATTACHED?

Yes
No

DESCRIBE ANY DEFECT

SUPPLIER/VENDOR/CONTRACTOR INVOLVED:

Yes No

NAME:

ADDRESS:

PHONE:

PROPERTY DAMAGE

WHAT DAMAGE DOES CUSTOMER DESCRIBE?

DESCRIBE ANY APPARENT INJURY OR DAMAGE:

CLOTHING SOILED?

Yes No

CLOTHING TORN?

Yes No

WHICH ARTICLE?

CAUSE OF SOIL OR TEAR:

OTHER DAMAGE:

IF DAMAGE TO CAR BY SHOPPING CART, ANSWER THE FOLLOWING:

a) WAS AN EMPLOYEE ASSIGNED TO GATHER CARTS?

Yes No

d) WAS THE WEATHER WINDY? Yes No

STORMY? Yes No

b) WAS LOT REASONALBLY CLEAR OF CARTS?

Yes No

e) IS PARKING LOT ANGLED/SLOPED? Yes No

FLAT ? Yes No

c) ARE CART CORRALS PROVIDED?

Yes No

f) INSPECT DAMAGE: REASONALBLE FOR CART TO CAUSE?

Yes No

OF RECENT ORIGIN? (NOT RUSTY)

Yes No

YEAR:

MAKE:

MODEL:

LICENSE PLATE #:

LOCATION OF DAMAGE ON CAR:

PHOTOS ATTACHED?

Yes No

CAUSE CODES: CHOOSE THE CAUSE CODE THAT BEST DESCRIBES THIS INCIDENT

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DATE OF THIS REPORT:	COMPLETED BY:	TITLE:

03 Bakery
11 Dairy
20 Flower Shop
23 Gen Mgr/MBA
37 Meal
46 Produce
53 Stockroom
Entrance
09 Checkout
12 Deli
21 Frozen Foods
24 Delivery
38 Office
50 Service Desk
60 Wall to Value
Other
08 Cart Storage
18 Employee Lounge
22 Gas Station
36 Liquor
42 Parking Lot
70 Sidewalk
70 Video

ALLEGES HARRASSMENT OR UNLAWFUL DETENTION
CAR DAMAGED IN LOT - ALL OTHER CAUSES
CHILD FELL FROM SHOPPING CART
CLOTHING CAUGHT ON SHARP OBJECT
FAINTING, PASSING OUT, DIZZINESS
FALSE ARREST
FOREIGN SUBSTANCE IN PRODUCT
ILL FROM EATING PRODUCT
INJURED BY ANIMAL OR INSECT
INJURED BY CONTACT WITH AUTOMATIC DOOR
INJURED BY PERSONS OTHER THAN EMPLOYEE
INJURED BY SPILLED PRODUCT
INJURED OPERATING MACHINE
OTHER MISCELANEOUS CAUSES
PROPERTY DAMAGED BY SHOPPING CART
PROPERTY DAMAGED BY SPILLED PRODUCT
SLIP, TRIP, FALL INSIDE
SLIP, TRIP, FALL OUTSIDE
STRUCK AGAINST OBJECT
STRUCK BY DOOR
STRUCK BY EMPLOYEE
STRUCK BY FLYING OR FALLING OBJECT
STRUCK BY SHARP OBJECT
STRUCK BY SHOPPING CART IN PARKING LOT
STRUCK BY SHOPPING CART IN STORE