Since F&B environments involve everything from physical kitchen hazards to customer-facing interactions, this template is designed to cover both Physical Injuries and Disciplinary/Conduct Issues.
Incident Type:
Injury/Illness
Disciplinary/Conduct
Near Miss
Date of Report:
Date of Incident:
Time of Incident:
Location of Incident:
Employee Name:
Job Title:
Supervisor on Duty:
Witness(es):
Name | Phone | |||
|---|---|---|---|---|
A | B | C | ||
1 | ||||
2 |
Please provide a factual account of what happened. Avoid speculation or emotional language.
Nature of Injury: (e.g., Burn, Cut, Slip/Fall, Chemical Exposure)
Part of Body Affected:
Equipment Involved: (e.g., Slicer, Fryer, Glassware)
Treatment Provided:
First Aid on-site
Refused medical treatment
Sent to Urgent Care/Hospital
Paramedics called
Nature of Infraction:
Policy/Procedure Violation
Attendance/Tardiness
Performance Issue
Customer Conflict
Professionalism/Conduct
Prior Warnings:
Verbal
Written
None
Employee Statement:
Why did this happen? (e.g., Lack of training, faulty equipment, negligence)
Immediate Action Taken:
Follow-up/Corrective Action: (e.g., Equipment repair, retraining, formal warning)
I hereby certify that the information provided above is true and accurate to the best of my knowledge.
Employee Signature:
Manager/Supervisor Signature:
Form Template Insights
Please remove this form template insights section before publishing.
In F&B, the specific area where an event occurs tells you everything about the physical state of the business.
A template should provide clear categories for the user to select from rather than relying on their own descriptions.
Including a dedicated section for witnesses is a cornerstone of a complete report.
This is a critical section for any F&B operation that uses machinery or specialized hardware.
A report is only useful if it leads to a solution.
Both the staff member and the supervisor must sign the document.
Mandatory Questions Recommendation
Please remove this mandatory questions recommendation before publishing.
To configure an element, select it on the form.