Title Page

  • Who has the issue or complaint?

  • Enter date

  • Is this a complaint (operator brought up an issue about a specific part of a station or job job) or an incident (an event happened resulting in injury)?

  • Did the operator report this issue before?

  • Enter a brief but detailed description of issue or complaint.

  • Station Name

  • If other was selected please enter station/area below

  • Please select which body part(s) are causing the problem (Check all that apply)

  • Who was the issue/complaint reported to?

  • Have you been rotated from this station previously?

  • Person who has issue or complaint please sign below.

  • Prison who is filling out report sign below

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