Incident/accident Log
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Conducted on
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Prepared by
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Location
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Division
- CCO
- CFO
- COO
- DWL
- ANL
- CORPORATE DIVISION
- CHRO
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Department (B2B, FINANCE, GM, INTERNAL AUDIT, CORE AND ACCESS, ETC.)
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AREA (INVENTORY, PLANNING, SALES, CORE & ACCESS, ETC.)
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Full name of Injured Person
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Contact number of Injured Person
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Home address of Injured Person
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Employee Category
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Month
- Jan
- Feb
- Mar
- Apr
- May
- Jun
- Jul
- Aug
- Sep
- Oct
- Nov
- Dec
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Date of Incident
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Police Notified
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Location of Incident
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Description of the Incident/accident or Near Miss
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Witness
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Witness Name
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Individual Injured
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Incident Type
- Near Miss
- First Aid
- Reported Only
- Lost Time
- Spill
- Vehicle Related
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Area Affected (head, right eye, left hand, etc.) be specific.
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Medical Attention
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Lost Days
