Page 21 - GFSI-Cover Module 2

INCIDENT REPORT FORM

DATE REPORTED: ___________________________________ DATE OF INCIDENT: __________________________
STORE/DEPARTMENT: TIME OF INCIDENT: __________________________
STORE PHONE NUMBER: DEPARTMENT CONCERNED: ___________________
STORE SUPERVISOR OR SHIFT TEAM LEADER ON DUTY: _______________________________________________

STAFF INVOLVED
ID NO NAME POSITION

CUSTOMER/S INVOLVED:
NAME CONTACT NUMBER / ADDRESS

PRODUCT/S INVOLVED:
Product Name:
Description:
Production Code / Best Before Date:
Quantity Affected:

DETAILS / DESCRIPTION OF THE INCIDENT:
Note: You may use the additional sheet below if necessary.

Reported by:

Name & Signature of Reporting Staff