Title Page
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Location
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Created on
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Prepared by
Property Damage Details
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When did the damage occur or when was it discovered?
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Property Description
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Property Damage Description
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Cause of the Property Damage
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Was anyone injured?
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Accomplish and attach an accident/injury report.
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Attach a picture
Completion
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Additional Notes/Comments
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Reporter's Name and Signature
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Safety Officer's Name and Signature
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Acknowledgment
