CUSTOMER INJURY FORM / WITNESS STATEMENT

Last Name: First Name, Middle Email Address: Are you a …?

Initial:
□ Patient
Department / Facility: Telephone: □ Associate
□ Vendor
□ Other

Home Address (street, city, state and zip code):

Date of Incident: Date & Time you Witnessed Incident: Location of Incident (be specific):

___/___/___ __ __ : __ __ AM/PM

Cause Part of Body Injured Additional Comments:

□ Caught In or □ Abdomen □ Hands COMMENTS:

□ Between Contact □ Ankle □ Hips
With Cut / □ Arm □ Internal
□ Laceration/ Back Knee
□ □ □
Scratch Chest Leg
Environmental □ Ears □ Neck
□
Exertion □ Elbow □ Not Otherwise
□
Pushing/ Pulling □ Eyes □ Classified
□ Face Shoulder
Slip, Trip or Fall □ □
□ Stepped on Fingers Toes
□ □
□ Object Foot Wrist
Strain □ Groin □ Other:_________
□
Struck by □ ______
□ □
Other:_________
□
Describe the incident in your own words. (include full names, departments, specifically what happened,
specific locations, times/dates):
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