Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
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Title/Role
Employee Incident Information
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Employee Name:
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What Task was being completed?
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Employee Title/Role:
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Time of Incident:
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Location:
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Specific Area of Location
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undefined
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Witnesses:
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Additional Person(s) Involved
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Incident Description including any events leading to or immediately following the incident:
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Employee Explanation of events leading to or immediately following the incident
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Resulting action executed planned or recommended:
Property Damage Description
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Item Damaged
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Description Of Damage
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EST. Value
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Item Image
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Incident Image
Details
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Employee Name:
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Employee signature:
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Reporting Staff Name:
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Reporting staff Signature:
Witness Statement
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Date and Time of incident
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Full Name of Witness
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Contact of witness
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Address of witness
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Statement of Witneess
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Signature
