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Run: Retail Associate Injury Report

Use this Retail Associate Injury Report template to document workplace injuries and near-misses in a store, including what happened, who was involved, treatm...

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Report Overview

Date of Report (required)

Time of Report (required)

Date of Incident (required)

Time of Incident (required)

Type of Incident (required)

Store Location (required)

Was a supervisor notified? (required)

Affected Associate

Associate Name (required)

Job Title / Role (required)

Department / Area (required)

Employment Status

Incident Details

Exact Location in Store (required)

Describe What Happened (required)

Use factual language. Include what the associate was doing, what happened, and any immediate hazards observed.

Possible Contributing Factors

Did an injury occur? (required)

Injury and Treatment Details

Body Part Affected (required)

Type of Injury

Treatment Received (required)

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 (required)

Reporter Role (required)

I confirm the information provided is accurate to the best of my knowledge. (required)

Yes No N/A

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.

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Email (required)

Your name (optional)

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