Retail Associate Injury Report

Injury and near-miss report form for retail associates to document what happened, body part affected, treatment received, witness names, and supervisor notification.

Report Overview

• Date of Report
• Time of Report
• Date of Incident
• Time of Incident
• Type of Incident
• Store Location
• Was a supervisor notified?

Affected Associate

• Associate Name
• Job Title / Role
• Department / Area
• Employment Status

Incident Details

• Exact Location in Store
• Describe What Happened
  Use factual language. Include what the associate was doing, what happened, and any immediate hazards observed.
• Possible Contributing Factors
• Did an injury occur?

Injury and Treatment Details

• Body Part Affected
• Type of Injury
• Treatment Received
• Treatment Details
  Briefly describe the treatment provided. Do not include unnecessary medical history.

Witnesses and Supervisor Follow-Up

• Witness Names
  Add each witness separately. Include only names and a brief contact method if needed for follow-up.
• Supervisor Notified
• Time Supervisor Was Notified
• Immediate Actions Taken
  Describe any immediate hazard control, cleanup, first aid, or escalation steps taken after the incident.

Acknowledgment and Submission

• Reporter Name
• Reporter Role
• I confirm the information provided is accurate to the best of my knowledge.
• PII and Safety Notice
  This form collects limited personal and incident information for workplace safety, incident review, and documentation. Do not include unnecessary medical details or sensitive personal data. Submissions may be reviewed by authorized supervisors, HR, and safety personnel.