Viva Chicken Employee Incident Form

Employee Incident Report
1) NOTIFY your District Manager immediately.

2) An employee that needs treatment should seek medical attention immediately (Manager and employee need to fill out/email to office same day as incident)

3)An employee that is not seeking immediate medical attention should fill out and sign incident report with manager ASAP after the injury

Employee Responsibilities:

1) Notify your supervisor immediately.

2) Seek medical treatment. (For all non-emergency injuries, please use preferred doctors/facilities - see google docs "workmans comp doctors")

3) Keep in contact with your employer. (Continually inform your employer of your condition and work capabilities)
Zurich Claim Number
Employee Name
Employee Address
Date/Time of Incident

MonthDayYear
Date
Finished Shift?
Employee Phone Number
Format: (000) 000-0000.
PLEASE SPECIFY STORE LOCATION
Where did the incident occur? (Example: Kitchen lobby during delivery list location address or approx intersections)
How did this incident occur? (Example: Cutting bread knife slipped and cut finger)
List the body parts injured and type of injury? (Example: Shallow cut on right index finger)
Date Employee Reported Injury to Store

MonthDayYear
Date
Witnesses? Name and phone number (comments optional if needed attach statement on separate page)
Witness 1
Witness 2
Will you receive treatment?
If you will receive treatment, who will provide it?

Other (Specify)
Employee Signature
Date

MonthDayYear
Date
Manager on Duty's Signature
Date

MonthDayYear
Date
GM/AM Signature
Date

MonthDayYear
Date
Additional Comments (continue on back if needed)
FOR OFFICE TO FILL OUT
Date Reported

MonthDayYear
Date
Date Filed

MonthDayYear
Date
HOST Name
Signature
Claim #
Additional Comments
Should be Empty:

Employee Incident Report