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Name
(Required)
Date and time of incident
Month
:
AM
Are you reporting?
(Required)
What (if any) body part is injured?
What type of injury do you have?
Bruising
Scratch
Cut
Sprain or strain
Burn (chemical or fire)
Foreign Body
Fracture
Dislocation
Internal
Amputation
Other
Type of treatment
(Required)
None
First Aid
Doctor
Hospital
Damaged Property?
Yes
No
Describe the incident with detail.
You could use the microphone on your keyboard
What caused the incident?
How bad could it have been?
Very Serious
Serious
Minor
What are the chances of it happening again?
Minor
Occasional
Rare
Did anyone witness the incident?
Yes
No
Witness name
Submit
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