Resource Manual

 Immediately following the incident, inform a

management team member,
A.6 - Glass and Brittle Plastics  Follow up by immediately completing and submitting an
Incident Report Incident Report Form.

Completed by: ______________________________

Date: _____________________________________

Information on the Incident

Nature of the Activity:

Place of the Incident:

Date : Time:

Exact Location of the Incident:

Employee responsible:

Description of Incident:

Complete this only if this Incident Affected Food Safety

Supervisor:

Shift:

Product Affected:

Lot # & Case #:

Action Taken:

Superviser Signature :

Additional Comments:

Onsite verification completed by: Date: Deviations/comments:

Record verification completed by: Date: Deviations/comments:

Premises Program: Glass and Brittle Plastics Incident Report Page 1 of 1

Issue Date: _______________________

Developed by: ___________________________ Date last revised: ____________________________

Authorized by: ___________________________ Date authorized: ____________________________