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 | |||
|---|---|---|---|---|
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.