Inspection
Victim
Name
Job Title
Store/Department
Work Address
Gender
Contact Number/Email
Alleged Offender(s)
Do you know the person(s) responsible?
Specify Name(s)
Approximate age
Gender
Relationship to the victim/reporting employee
Details of the Incident
Type of Incident
Description of Incident
Description of any injury, illness or property damage
Take/ upload photo evidence of incident, environment, person(s) involved
Date reported to regulatory authority
Completion
Observations and comments
Name & signature of person reporting