Information
Person filling out form
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Person Reporting Classification
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Name?
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Company?
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Site Contact?
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Name?
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Company representing?
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Site Contact?
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Name?
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Role?
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Department?
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Manager?
Person Reporting Incident
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Person Reporting Classification
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Name?
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Company?
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Site Contact?
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Name?
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Company representing?
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Site Contact?
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Name?
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Role?
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Department?
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Manager?
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Conducted on
Incident Details
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Incident Type?
- Pain/Discomfort
- INJURY - No Treatment
- INJURY - First Aid
- INJURY - Restricted Work
- INJURY - Medical Treatment
- INJURY - Lost Time
- Property / Plant / Equipment Incident
- Environmental Incident
- Vehicle Incident
- Near Miss / Close Call
- Unsafe Act
- Customer Compliant or Quality Incident
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Location of incident?
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Onsite location?
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Offsite location?
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Date and time of incident
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Time the person involved started shift?
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What the incident reported immediately?
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Reason for delay?
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To whom was the incident reported?
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Detailed description of incident. (Include environmental conditions at time of incident)
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Was there any witness(es)?
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Witness details?
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Immediate actions post incident?
Injury Details?
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Did an injury occur?
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Injury section?
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Injury location?
- Arm / Shoulder
- Knee / Leg
- Head / Face / Neck
- Chest / Abdomen
- Eye/s
- Finger / Hand / Wrist
- Toe / Ankle / Foot
- Inner Ear / Outer Ear
- Lungs / Respiratory
- Back
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Injury type?
- Cut / Laceration / Graze
- Open Wound
- Strain / Sprain / Tear
- Bruise / Swelling
- Crush
- Inhalation Fume / Dust
- Fracture / Dislocation
- Electric Shock
- Foreign Body
- Burns
- Skin Irritation / Rash
- Amputation
- Illness / Diseas
- Hearing loss
- Bite
- Other
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Treatment provided?
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Treatment provider?
Property / Plant / Equipment Damage?
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Was property / plant / equipment damaged?
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Name?
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Make / Model?
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Picture
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Does operation require license?
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Photo of license?
Signatures
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Person filling out form
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Person reporting incident
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Manager
