Title Page
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Project Name
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Accident / Incident Date
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Prepared by
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Location
Accident / Incident Details
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Description of Accident / Incident:
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Location onsite:
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Machinery / Equipment Involved:
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Chemicals / Materials Involved:
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First Aid Treatment Provided:
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Hospital Treatment Provided:
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Hospital Detention Necessary:
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Name / Address of Witnesses:
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Injury or Dangerous Occurrence as defined in Regulations requiring reporting to Enforcing Authority:
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Comments / Recommendations / Action Taken:
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Signature:
