Skip to menu
Skip to footer
Current Specials
About
Our Story
Recipes
Quality Standards
Labeling Guide
Careers
Community
Supporting Local Schools
Education & Food Activism
Our Sustainability Efforts
Request A Donation
Contact Us
Newsletter
Order Takeout
Shop Online
Remove
My Store:
Select Store
Injury Report
Injury Report Form
Location:
(Required)
Fairfax
1966 Commissary
Mill Valley
Date of Injury:
(Required)
MM slash DD slash YYYY
Time of Injury
(Required)
Floor Manager Responding:
(Required)
First
Last
Floor Manager Email:
(Required)
Employee Name:
(Required)
First
Last
Employee Initials:
(Required)
Department:
(Required)
Body Part Injured (Include Right or Left Side):
(Required)
Type of injury (burn, cut, strain, fall, impact, etc):
(Required)
Brief description of cause of injury:
(Required)
Exact location of incident (be specific):
(Required)
Onsite Called?:
(Required)
Yes
No
Was First Aid Given (by Good Earth or by Onsite)?
(Required)
Yes
No
If so, describe First Aid given:
Onsite Suggestions:
Employee Status:
(Required)
Kept Working
Went Home
Went to ER
Went to Worker's Comp Clinic
CAPTCHA