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Incident Report Submission.

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Company: | Company ID: | Email:

Incident Type

Date Occurred

Site Name

Name

Notes

Incident Description

Involved Users

Incident Location

Department Involved

Incident Category/Classification

Was this incident picked up with Risk Assessment?

Should the risk of this hazard be assessed?

Was anyone injured?

Injury Description

Select the affected Body Part

Effect on the Person Involved

Expected Period of Disablement

Machine/Process Description

Applicable General Agency

Applicable Environmental Agency

Unsafe Act

Unsafe Condition

Personal Factor

Job Factor

Immediate Action Taken

Investigator Name