Title Page
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Conducted on
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Prepared by
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Location
Hazard and Incident Details
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Incident Category
- Injury/ Illness
- Property Damage
- Near Miss
- Hazard
- Risk
- Other
1. Injured Person (if applicable)
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Take photo of injury (where appropriate)
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Name
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DOB
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Sex
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Contact Number/ Email
2. Hazard/ Incident Details
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Occurred
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Reported
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Location of incident
- Pilot Manufacturing
- Analytical lab
- TC lab
- Storage areas/warehouse
- Workspace/desks
- Kitchen
- Small kitchen
- Parking lot
- Outside/exterior property
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Describe exact location
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Description of hazard incident
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Description of any of injury, illness or property damage
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What potential consequence(s) exist if the hazard is not addressed?
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What is the level of the consequence(s)?
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What is the likelihood of getting injured?
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How serious would the injury be?
- No injury/not applicable
- Onsite first aid required
- Moderate injury requiring medical care
- Serious injury requiring hospitalization
- Long term injury
- Permanent disability
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What would be a reasonable foreseeable outcome if an incident occurred?
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Risk rating
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How soon is a response required?
- Not urgent, but needs to be addressed [10-20 business days]
- Low priority [5-10 business days]
- Medium priority [1-5 business days]
- High priority [12-24 hrs]
- Immediately [0-3 hrs]
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What is the corrective action required to fix this?
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Do you recommend a job hazard analysis be conducted on this?
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Take/upload photo evidence of incident/environment/etc. involved
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Date reported to regulatory authority (leave blank if not required)
3. Witness Statements (if applicable)
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Witness
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Name
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Contact
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Statement
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Witness signature (if applicable)
4. Completion
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Observations and comments
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Name and signature of reporting person