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Safety Incident Report
*
Indicates required field
Date
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Time
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Witness name
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Job Title
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Phone
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Background information
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Location of incident
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Did the incident result in injuries?
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Yes
No
If yes, list injured persons (name - position)
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Did the incident result in damage to property?
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Yes
No
If yes, list damage
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Description of incident
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What causal factors were involved? (e.g., lack of policy, lack of training, unsafe act, broken machinery, procedure, etc.)
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What corrective actions are being taken to prevent it from happening again, if any?
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Submitted by - Name
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Job Title
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Phone
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Submit