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Automotive or field equipment
Exact Description of Occurence
According to you what was the unsafe situation or action?
What are the preventive and corrective procedures?
Witness of incident
Name of witness
Are instructions been given before starting the job?
Is Medical Treatment required?
Name of Clinic or Hospital
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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