Incident Report — LM Restaurant Group

Internal use only. Completing this report does not in any way constitute an admission of liability for the alleged incident and is without prejudice to LM Restaurant Group. Complete a separate report for each affected person. Do not give a copy of this report to the injured party.

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Submission Details

Submitting Manager *

Manager Email *

Location *

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Affected Person

Who was affected? *

Guest LM Employee Vendor / Contractor Other

Full Name *

Approximate Age

Address

Home / Cell Phone

Work Phone

Nature of Injury / Body Part Affected

Hotel guest?

Yes No

Room No.

Check-in / out Dates

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Reported

Reported By (Name)

Reported To (Name)

Position of Person Reported To

Time Reported

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Emergency Services

Fire Dept. called?

Yes No

Police called?

Yes No

Officer's Name / Badge #

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Treatment Information

First Aid

Yes No

Who provided?

Doctor

Yes No

Name & address?

Ambulance

Yes No

Where taken?

Refused treatment?

Yes No

Comments

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Description of the Incident

What happened? *

Stick to observable facts. Use the Evidence Checklist below to make sure the description covers each point.

Evidence Checklist

Check each item you have documented.

Physical conditionse.g. weather, flooring, lighting, footwear Details of who had access to the incident area Condition of equipment & tools Details of relevant procedures & training Tangible evidencee.g. photographs, video, measurements & diagrams Protective systemse.g. signs, barriers, personal protective equipment

Evidence Notes

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Photos

Add photos Tap to take or choose up to 4 photos of the area, conditions, or injury

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Witnesses

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Action Taken by Location

Actions taken

Action Checklist

Attend the incident, provide any necessary assistance, and make the area safe Arrange medical treatment if necessary Speak to the affected person if possible, and any witnesses — take statements if appropriate Did NOT express an opinion on the cause of the incident or the location's liability, or offer to meet any of their expenses Conduct a detailed physical inspection of the area Complete this form and attach any witness statements or relevant forms of evidence

Submitting this form sends a copy to the appropriate people (GM / Duty Manager / HR) automatically.

Also send a copy to (optional)

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Person Completing Form

Signature *

Sign here

Name *

Position *

Date *

By submitting, I confirm this report is accurate and complete to the best of my knowledge.

For internal record purposes only · Do not give a copy of this report to the injured party

Submission Details

What, When & Where

Affected Person

Reported

Emergency Services

Treatment Information

Description of the Incident

Photos

Witnesses

Action Taken by Location

Person Completing Form

Review Incident Report