Injury Incident Report Employee Submitting Report(Required) First Last Injured PartySelect from DropdownMyselfOtherIncident Type(Required)Select from DropdownReStore CustomerReStore StaffReStore VolunteerStaffVolunteerName of Volunteer Injuryed(Required) First Last Name of Employee Injured(Required) First Last Name of Customer Injured(Required) First Last Date Injury Occurred(Required) MM slash DD slash YYYY Time of Injury Hours : Minutes AM PM AM/PM Address of Incident(Required) House or Project # if Applicable Street Address City State / Province / Region Detailed Description of What Happened to Cause the Injury(Required)Detailed Description of Injury(Required)What Action Steps Were Taken to Address Injury(Required)At this Time, Does the Injured Party Plan to Seek Medical AttentionSelect from DropdownNoYesList Witnesses of Incident if ApplicableAre There Photos or Video Footage of the Injury?(Required)If yes, please email to Brent Bohanan within 24 hours. Select from DropdownNoYesAdditional Notes (Include any helpful information here, that could not be captured in other fields)
