CMC Incident Form
To be completed after a course in case of an incident
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Lead Instructor Name *
Other Instructor Names (if applicable)
Course Name & dates *
Date & time of incident *
Location of incident *
Description - what happened? *
Analysis - What were the causes? *
How bad could it have been? *
What is the likelihood of this incident occurring again without controls? *
What action(s) has/have been taken to reduce the likelihood of a recurrence? (include when and by whom) *
Injury or Illness
Name of person *
Affected body parts *
Type of Injury *
Required
Treatment *
Required
Notifiable Injury? *
Details or comments
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