Title Page
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Document No.
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Document title
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Date of incident
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Location of incident
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Number of employees that maybe have been injured
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Description of the incident
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What kind of work were you doing?
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What in your opinion can be done to prevent this accident from reoccurring? Be specific in regard to corrective actions you believe need to be taken.
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Please sign
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Witness to incident
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Assessed severity rating
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Assessed frequency rating
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Safety committee review date (leave blank)
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Safety committee chairman signature
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Department manager signature
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Corrective action taken?
