Title Page
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Conducted on
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Prepared by
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Location
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Statement of the incident
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Photo's of the incident, work area, property, person
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Date and Time of the incident
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Are there workers involved?
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List names and Company
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Did the injured seek medical attention?
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How were they transported?
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Did any of the injuries result in a hospitalization, amputation, loss of a eye or death?
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Was there property damage?
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Was there equipment damage?
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List any witness names/companies
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List Competent Persons on site:
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What were you doing during the time of the accident?
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Were company procedures being followed?
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What were they?
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What was the physical condition of the area when the accident occurred?
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What action could of prevented the accident or minimize the effect?
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Any corrections need to made on site
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What were the corrections, were they completed and by who?
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Was the work resumed?
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Is OSHA involved?
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Notes:
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