Restaurant Server Sharps Injury Incident Form
Employee Information
Employee Name
Employee ID
Position
Supervisor
Incident Details
Date of Incident
Time of Incident
Location of Incident
Type of Sharp Involved
Activity Being Performed
Description of Incident
Describe what happened
Injury Details
Body Part Injured
Describe the Injury
First Aid Given
Follow-Up
Was Medical Attention Sought?
Yes
No
Recommendations to Prevent Future Incidents
Reporting
Form Completed By
Date