Staff Member Incident Report

Please complete all items

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Incident date:(Required)

Incident time:

Time started work:(Required)

Your Name:(Required)

First Last

Badge Number:(Required)

Position Title:(Required)

Location of Incident:(Required)

What happened?(Required)

What caused this incident?(Required)

What could have prevented this?(Required)

Were you injured, even slightly?(Required)

Yes

What body part was injured?(Required)

Were safety devices being used?(Required)

Yes

If yes, what safety device were you using?(Required)

Date of Report:(Required)

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