River Road Restaurants
Accident Report Form
 FOR INTERNAL USE ONLY
Location of Accident:
Date of incident:    Time of incident:   
Who was involved in this incident?
 Employee     Guest     Other
Was the guest's check discounted? Yes     No    
Type of incident: Burn Cut Food Contamination

Slip/Fall Property Damage Police Call

Other

If this was a slip/fall, was the floor wet? Yes No
If so, why?
Name:
Address:
City, State, Zip:
Telephone #:
including Area Code
Description of Accident:

 Please describe exactly what happened. Be as specific as possible
Body Part Affected:
Was First Aid Performed? Yes No Was Medical Treatment Requested? Yes No
Was an Ambulance Dispatched? Yes No Did the Person Leave in an Ambulance? Yes No
List all employees who witnessed the incident:
List all guests who witnessed the incident:
Any additional comments you feel are necessary:

FOR EMPLOYEE INCIDENTS ONLY:
Will the employee lose time as a result of this incident? Yes No
Was the employee following established safety procedures? Yes No
If not, why?

Name of person completing this form:
READ AND CERTIFY BY CHECKING THE BOX BELOW:
By checking the box below I certify under penalty of perjury that I am the person named above as completing this form and that I have filled out this report truthfully. I understand that falsely filing this report may result in disciplinary action against me including termination and/or legal action.
Check to Certify