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Investigation/Safety Incident Report
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Injured Name: *
Injury Date: *
MM
/
DD
/
YYYY
Injury Time: *
Time
:
Department: *
Division: *
Incident Location: *
Part of Body Injured: *
Date Accident Reported: *
MM
/
DD
/
YYYY
If accident was reported late, why?
What time did the employee begin work? *
Time
:
What was the employee doing when the accident occurred? *
Describe Incident/How it happened (Be Specific): *
Were there any witnesses? List names: *
Were other people involved?  If so, how? *
Was any property damaged as a result of the injury? *
Was the employee engaged in any unsafe acts which led to the injury? *
Any hazardous conditions at the time of the injury or a result of the accident?
Has the employee received any 1st aid onsite?  If so, what? *
Is employee receiving medical treatment offsite?  If so, where? *
Could you see this accident happening again? If yes, frequently, occasionally or rarely? *
What could this have been avoided? *
Are there interventions needed from another department to prevent this from happening?  If yes, who? *
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