Viva Guest Incident Report

Viva Guest Incident Report
PLEASE SPECIFY LOCATION BELOW
Date of Accident

MonthDayYear
Date
Time of Accident

Hour Minutes

AM/PM Option
Manager on Duty at Time of Accident
Employee Completing this report

First NameLast Name
Did you witness the accident/incident?
If not, who informed you of the accident?
Outside Weather Conditions (Choose all that apply)

Other
Give the exact location of the accident at the store
Description of the Accident or Incident
Name of Manufacturer/supplier of product, equipment, merchandise involved
Did you inspect the location immediately after the incident?
Exact time of inspection
Did you photograph the location?
Please upload the photos

Cancelof
Was the location clean?
Was the location dry?
Any signs posted?
When was the last time area was cleaned?
By whom?
When was the last time area was checked?
By whom?
Describe lighting conditions?
Injured Person Information
Name of Injured
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Email
example@example.com
Name of Injured's Employer
Employer's Phone
Occupation
Was the injured person wearing glasses?
Type of footwear injured person was wearing
Describe the injury
Describe medical care at the scene
Did injured person seek immediate medical care?
Hospital, clinic, or doctor injured sought treatment with
Taken by ambulance or left on own will?
Name of injured person's companion (if any)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Companion's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Injured Person
Witness #1

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Witness #2

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Witness #3

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Viva Guest Incident Report

Injured Person Information