Retail Customer Accident Report Sheet
Date of Accident
Time of Accident
Store Location
Reported By (Employee Name)
Customer Name
Customer Contact Number
Description of Accident (include exact location, actions, etc.)
Injury Description (if any)
Was medical attention required?
Yes
No
If yes, by whom?
Witness Name(s)
Witness Contact Info
Action Taken/Remarks
Manager/Supervisor Name
Date Submitted