Butcher & Rose - Guest - CMR RISK & SAFETY HEADQUARTERS

CMR RISK & SAFETY HEADQUARTERS

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Guest Incident Reporting Form

* Indicates required field

Store Number & Name *

Manager on Duty *

Date of Visit *

Time *

Guest Name *

Guest Contact Phone Number *

Incident *

Alleged FBI Allergy Fall Foreign object Medical emergency Other

Description of Incident *

Guest would like to be contacted by Home Office *

They are unsatisfied with guest recovery at the store level They are seeking compensation beyond a refund or complimentary gift card (i.e., medical bills or property damage)

Upload File - Guest Check *

Max file size: 20MB

Please upload any related Guest check, photos, etc.

Upload File - Photo *

Max file size: 20MB

Please upload any related Guest check, photos, etc.

Upload File - Misc. *

Max file size: 20MB

Please upload any related Guest check, photos, etc.

If guest injury occurred, please fill out below:

What was the guest doing when the incident occurred? *

Describe the injury including specific body parts injured *

Post Injury Actions Taken *

Assured guest comfort & safety Purchase of meal Paramedics called First aid Other

If guest illness related, please fill out below:

Comments or Symptoms Mentioned *

How was the guest made a Raving Fan? *

Check refunded Sent a complimentary gift card Guest declined all offers Other

Did you use the LifeVac anti-choking device?

Nature of the blockage *

If known, specify food if applicable.

Number of times LifeVac was used *

How many times did you have to push and pull before item became dislodged?

Was guest conscious at time of LifeVac use? *

Yes No

Was the hazard successfully dislodged? *

Yes No

Position of guest at time of LifeVac use *

Seated Laying down Standing Other

Witness contact information (when applicable):

Witness Name *

First

Last

Witness Phone Number *

Associate or Guest *

Associate Guest

Witness Name *

First

Last

Witness Phone Number *

Associate or Guest *

Associate Guest

Witness Name *

First

Last

Witness Phone Number *

Associate or Guest *

Associate Guest

Submit

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Home
Associate Safety Acknowledgement
- CMR Associate Safety Acknowledgement
- RBRT Associate Safety Acknowledgement
Specialty Incident Reporting
Ocean Prime Incident Reporting
Rusty Bucket Incident Reporting
CMPE & HO Incident Reporting
- Cameron Mitchell Premier Events >
  - CMPE - Associate
  - CMPE - Guest
- Home Office >
  - Home Office - Associate
  - Home Office - Guest