Incident Report

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PLEASE NOTE: Nothing will be created until the completion of this incident form and a confirmation email has been received. Your progress will be automatically saved if you close this screen.

General Incident Information

Incident Date*

Incident Time*

Store Number*

Location Information

Address*

City*

State*

ZIP Code*

Location Phone #*

Incident Details

Location Type*

General Location*

Specific Location*

Incident Description*

Contractor/Vendor?

Ambulance Transport?

Seeking Medical Treatment?

File Attachments

Please upload the following files:

Customer Incident Report (scan of the paper document)
Photos of the incident area from multiple angles
Associate Statements (scan of the paper documentation)

Reminder: 2 copies of video, 1 hour prior to the incident through 1 hour post-incident, should be retained. Label docs with the incident number, date of incident, and customer name. Video cannot be uploaded to the portal at this time; please retain 1 copy of the video with the incident folder at the store and send the other to Risk Management at corporate using the green tote. If you are a remotely monitored store, Risk Management will work with the ROC.

Drag and drop files here, or