Information
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Document No.
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Report Title
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Jobsite
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Conducted on
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Prepared by
GENERAL INFORMATION
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TYPE OF INCIDENT
- NEAR MISS
- PROPERTY DAMAGE
- FIRST AID
- DR VISIT
- EMERGENCY
- FATALITY
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DATE AND TIME OF INCIDENT
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DATE AND TIME REPORTED
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JOBSITE
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LOCATION OF INCIDENT
INCIDENT OBSERVATIONS
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WHAT DID YOU OBSERVE AT THE INCIDENT SITE?
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WHAT DID YOU DO DURING/AFTER THE INCIDENT?
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WHY DID THE INCIDENT OCCUR?
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WHY DID THE ACCIDENT OCCUR? (IF APPLICABLE)
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WHAT ACTIONS HAVE OR WILL BE TAKEN TO PREVENT RE-OCCURRENCE?
CERTIFY
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SUPERVISOR'S SIGNATURE
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SAFETY COORDINATOR'S SIGNATURE