Hazard - Accident - Incident - Risk Reporting Form
If an injury required first aid treatment, please complete a medical incident form as well.
Your Name *
Your answer
Email or Phone
So that we can follow up with you for more details if needed and advise the outcome of the report
Your answer
Date of Incident or Hazard Identification *
MM
/
DD
/
YYYY
Functional area of Incident *
Describe Hazard / incident / Risk *
Your answer
Describe Possible Solutions
If you have suggestions about how we solve this issue, we'd like to hear them - If you are not sure that's fine - thanks for reporting the issue.
Your answer
Are you a Safety Supervisor
Click Yes, If you are adding Analysis, or No to submit the form
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