Document Employee Incident Macayo Location*Select LocationAhwatukeeASU TempeAvondaleChandlerGlendaleGoodyearLitchfield Park (Buckeye)Mesa DobsonQueen CreekScottsdaleSuperstition SpringsSurpriseDate* MM slash DD slash YYYY Name of General Manager*Manager on Duty*Type of Accident*Select OneCriminal ActFood/Chemical PoisoningGlass/Knife CutSlip & FallOtherIf other, please explain*# of Employees Injured*Select OneOneTwoThreeEmployee Full Name, One Employee*Employee Full Name, Two Employees*Employee Full Name, Three Employees*Were minors involved?*Select OneYesNoWas 911 called?*Select OneYesNoWas Employee sent to Concentra?*Select OneYesNoHas Director of Operations been notified?*Select OneYesNoPlease attach completed Employee Incident Report*Max. file size: 150 MB.Please attach a picture of incident area or injury (if applicable)Max. file size: 150 MB.Submitted By*Position (ex: DO/GM/AM)*Contact Number*
