Homak Intake
Accident Investigation Report
Store 34994
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Employee name *
Employee cell phone # *
Job title of injured employee *
Select…
Crew Member
Maintenance
General Manager
Shift Manager
RDM or Assistant Manager
Kitchen Manager
Other
Date of accident *
Time accident occurred *
Date employee reported accident *
Describe how the accident occurred (ask the employee to show you how) *
Explain how this accident can be prevented in the future *
Part(s) of body affected
What workplace condition, practice, or equipment contributed to this incident?
Was a safety rule violated? *
Select…
Yes
No
If yes, which rule?
Was the unsafe condition corrected immediately? *
Select…
Yes
No
What has been done to correct the condition?
Interim actions taken until fully corrected
Where did the accident occur *
Front Lobby
Front Counter
Fryer
Produce Prep
BDAP
Drive Thru Cash
Grill
Trash Corral
Restroom
Drive Thru Present
Sandwich Prep
Parking Lot
Stairs
Basement
Dry Storage
Dish Wash Area
Walk-in Cooler
Walk-in Freezer
Break Room
Dining Room
Other
Accident caught on video? *
Select…
Yes
No
Copy of video saved? *
Select…
Yes
No
Witness name(s) and cell phone number(s)
Medical treatment information *
Select…
Declined Medical Treatment
First Aid Only
Medical Clinic
Emergency Room
Employee claim form (DWC-1) / refusal to treat *
Employee was provided with an Employee Claim Form (DWC-1)
Employee declined medical treatment and was provided with a Refusal to Treat Form
Form completed by — name *
Form completed by — job title *
Date completed *
Submit
