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Captures store information, incident timing, and the on-duty manager, then records the reporter’s identity and event type. Includes sections for injuries, involved parties and contact details, a detailed narrative of what occurred and contributing factors. 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Not to be  \nsubmitted as a formal incident report.  \nStore Information  \n1. Store number:  \n2. Store address:  \n3. Date of incident:  \n4. Time of incident:  \n5. Manager on duty:  \nPerson Completing This Report  \n1. Name:  \n2. Role/position:  \n3. Date and time report completed:  \n4. Type of Event  \na. Check one: Incident (resulted in harm, loss, or property damage) Near miss (could have resulted in harm or loss, but did not)  \n5. Category:  \na. Check all that apply: Customer behavior / conflict Employee injury or illness Theft / robbery / security issue Slip, trip, or fall Hazardous condition (spill, obstruction, broken equipment, etc.) Product/safety issue (food safety, agerestricted items, etc.) Other (describe):  \nPeople Involved  \n1. Was anyone injured? Yes / No  \n2. Names and roles (customer, employee, vendor, other):  \n3. Contact information (if available):  \nDescription of What Happened  \n1. Describe the incident or near miss in detail.  \na. Include: What happened Where in the store it happened What led up to it What you and others did in response  \n2. Were any safety procedures followed?  \na. If yes, which ones (for example: de-escalation steps, emergency response steps, equipment use, etc.)?  \n3. Were any safety procedures not followed or unclear?  \na. If yes, explain. Immediate Response and Actions Taken  \n4. What immediate actions were taken?  \na. (For example: cleaned spill, moved customer to safe area, called 911, notified manager, reviewed security cameras.)  \n5. Was medical attention needed? Yes / No If yes, describe (first aid, ambulance, hospital visit, etc.):  \n6. Was law enforcement or another external party contacted? Yes / No If yes, who was contacted and when? Contributing Factors ( if known)  \n7. Did any of the following contribute?  \na. Check all that apply: Inadequate lighting Wet or cluttered floor Equipment issue or malfunction Policy not followed Policy unclear or not known Customer behavior Staffing levels / workload Training issue Other (describe):  \nPrevention and Follow-Up  \n1. What could be done to prevent this type of incident or near miss in the future? (For example: more frequent safety talks, additional training, clearer signage, policy change, equipment repair.)  \n2. Does this incident suggest a need for training or refresher training in any of these areas?  \na. Check all that apply: Customer service De-escalation Safety procedures (store security, handling difficult situations) Emergency response Product safety (food handling, temperature control, age-restricted items)  \nOther (describe) :  \nManager Review  \n1. Manager name (print):  \n2. Date reviewed with staff:  \n3. Summary of discussion with team (key points, decisions, and one or two improvements to implement):  \n4. Follow-up actions and deadlines (who will do what, and by when?):  \n5. Manager signature:  \n6. Date:","cbCaisM6Vw2CjDzv","https://ap.wps.com/l/cbCaisM6Vw2CjDzv","pdf",103541,"English","# Store Information\n## Person Completing This Report\n## Type of Event\n## People Involved\n## Description of What Happened\n## Immediate Response and Actions Taken\n## Contributing Factors\n## Prevention and Follow-Up\n## Manager Review","[{\"question\":\"What information does the incident report form require under Store Information?\",\"answer\":\"It asks for the store number, store address, date of the incident, time of the incident, and the manager on duty.\"},{\"question\":\"How does the form distinguish an incident from a near miss?\",\"answer\":\"It provides check options: Incident applies when there is harm, loss, or property damage; Near miss applies when the situation could have resulted in harm or loss but did not.\"},{\"question\":\"What fields are included in the Prevention and Follow-Up section?\",\"answer\":\"It prompts for ideas to prevent future occurrences, whether training or refresher training is needed, and which training areas apply, followed by any other relevant descriptions.\"}]","Incident Report Form - Sample Checklist | PDF",1789223884]