Incident reporting form for near misses, injuries, and property damage
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Other Incident Type:
Date and Time of Incident:
Worker(s) involved in the incident:
Witnesses (workers and/or others):
Select "yes" to send a copy of this form to management.
I hereby certify that all information is accurate and that an actual inspection was conducted as per company policy.
Crew Manager's Printed Name & Signature:
Worker's Printed Name & Signature:
Witnesses Printed Name & Signature:
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to
take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment;
or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is
permissible in your workplace or jurisdiction.
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